Diabetes management in special clinical settings

Diabetes management changes profoundly when the disease occurs in a special clinical setting. In these situations, the issue is not merely achieving good average glycemic control, but adapting targets, medications, monitoring, and follow-up intensity to conditions that alter biological risk, patient vulnerability, and the very meaning of metabolic control. Pregnancy in a woman with pre-existing diabetes, a frail older adult, a surgical admission involving perioperative fasting, or an infectious illness with reduced food intake are not simply organizational variations of routine diabetes care. They are scenarios in which priorities, intervention thresholds, tolerance of hypoglycemia, risk of ketosis, the need for treatment simplification, and the intensity of clinical surveillance all change.

Across all these settings, the common principle is that diabetes cannot be managed automatically. The usual treatment may become temporarily inappropriate, and what was correct under stable conditions may become hazardous when insulin resistance, fasting, dehydration, hormonal stress, cognitive decline, loss of independence, or insulin requirements change rapidly. Management in special settings therefore requires a more dynamic interpretation of the disease: identifying the dominant risk at that moment, determining which medications should be continued, reduced, or withheld, and deciding which targets remain appropriate and which should be temporarily reformulated to prioritize maternal and fetal safety, hemodynamic stability, prevention of hypoglycemia, or reduction of the risk of acute decompensation.

This page addresses four major scenarios: pregnancy, with particular attention to pre-existing type 1 and type 2 diabetes; older age, in which the clinical focus shifts from numerical control alone to preservation of independence and safety; surgery, which requires precise management of the preoperative, intraoperative, and postoperative periods; and infections, in which intercurrent illness and dehydration may rapidly precipitate severe hyperglycemia, ketosis, or decompensation. Gestational diabetes, already covered on the dedicated page, is mentioned here only when necessary to clarify the distinction from pre-existing diabetes in pregnancy.

The first cross-cutting principle is reassessment of targets. In special settings, a glycemic target is never an abstract number to be applied automatically, but the result of balancing expected benefit against immediate risk. During pregnancy, the target becomes more stringent because hyperglycemia directly affects congenital malformations, fetal growth, neonatal outcomes, and obstetric risk. In a frail older adult, by contrast, pursuing excessively low values may cause more harm than benefit, particularly when it increases the risk of hypoglycemia, falls, delirium, hospitalization, or loss of independence. In the perioperative period and during acute infections, the main issue is not glycated hemoglobin itself, but avoiding wide fluctuations, fasting-related hypoglycemia, and persistent hyperglycemia that promotes infection, delayed healing, ketosis, or hyperosmolar crises.

The second principle is treatment review. Every special setting requires asking whether the current regimen remains appropriate under the new physiological or organizational conditions. Pregnancy progressively changes insulin sensitivity and raises issues of medication safety. Advanced age often reduces functional reserve, self-management capacity, awareness of hypoglycemia, and tolerance of treatment complexity. Surgery introduces fasting, metabolic stress, dehydration risk, and the need to plan basal insulin continuity precisely. Acute infections increase counterregulatory hormone secretion, alter appetite, worsen hydration, and make discordance between food intake and medication doses more likely.

The third principle is the hierarchy of priorities. In special settings, not every objective has the same importance at the same time. In a woman with type 1 diabetes in late pregnancy, the priority is sufficiently tight normoglycemia without an excessive increase in severe hypoglycemia risk. In an older adult with cognitive decline and polypharmacy, the priority may be to simplify the regimen, reduce medications with a higher hypoglycemia risk, and establish realistic targets. In a patient scheduled for surgery, the priority is to reach the procedure with reasonable metabolic stability, withhold medications that pose perioperative risk in a timely manner, and ensure insulin continuity. In a patient with fever, vomiting, or diarrhea, the priority becomes preventing hyperglycemia from progressing to ketosis, acidosis, dehydration, or acute kidney injury.

The fourth principle is more intensive monitoring. When the context changes, glycemic data must be interpreted more frequently and in greater depth than in ordinary life. Pregnancy requires tighter profiles and often more advanced technological support. During the perioperative period and infections, frequent monitoring allows potentially dangerous deviations to be corrected early. In older adults, by contrast, monitoring should be calibrated to its actual clinical usefulness, avoiding both insufficient surveillance and an excessive burden of measurements that are unsustainable or difficult to interpret.

The final principle is the central role of the care setting. In special situations, a favorable outcome depends much less on any single medication and much more on integration among the diabetologist, general practitioner, obstetrician, surgeon, anesthesiologist, internist, nurse, caregiver, and community care network. Correct treatment isolated from an effective organization is more likely to fail. Diabetes management in special settings is therefore, even before it is pharmacology, a form of adaptive medicine based on coordination and anticipation of risk.

Pregnancy is the special setting in which diabetes changes its clinical meaning most radically, because the target of care is not maternal health alone but the maternal–fetal unit. In women with pre-existing type 1 or type 2 diabetes, obstetric and neonatal risk is already increased before conception and rises in relation to the quality of glycemic control, disease duration, chronic complications, obesity, hypertension, and current therapy. Miscarriage, congenital malformations, fetal death, preeclampsia, preterm birth, macrosomia, birth trauma, neonatal hypoglycemia, and admission to neonatal intensive care become more likely when conception occurs under suboptimal metabolic conditions. Correct management of diabetic pregnancy therefore begins with preconception care, not with the first obstetric visit.

Preconception counseling should become a routine component of follow-up for every woman of childbearing potential with diabetes. This means regularly discussing reproductive intentions, contraception until adequate control is achieved, medication safety, complication status, and the organizational burden of a future pregnancy. This is not a formal exercise. The literature clearly shows that preconception preparation reduces adverse outcomes, whereas lack of planning exposes the pregnancy during the most vulnerable months of embryonic development, precisely when the woman may still be taking unsafe medications or have substantial uncorrected hyperglycemia.

In practical terms, the preconception phase requires metabolic control as close as possible to pregnancy targets without causing problematic hypoglycemia. NICE recommendations indicate a target HbA1c below 48 mmol/mol, equivalent to below 6.5%, if this can be achieved safely, and strongly advise against conception when HbA1c exceeds 86 mmol/mol, equivalent to 10%, because of the excess risk. During this phase, HbA1c should be measured frequently, potentially monthly; self-monitoring or continuous glucose-monitoring data should be reviewed carefully; and the entire treatment regimen should be reassessed. Women with type 1 diabetes planning pregnancy must also have access to blood ketone testing, because hyperglycemia associated with illness or reduced intake can progress more rapidly to ketosis.

Preparation concerns more than glycemia. Modifiable risk factors must be corrected or reduced, including overweight, poor blood pressure control, smoking, sedentary behavior, disorganized eating, exposure to teratogenic medications, and lack of vitamin supplementation. A woman with diabetes planning pregnancy should take high-dose folic acid, generally 5 mg daily until the twelfth week, and should be reassessed for end-organ complications. Retinopathy requires ophthalmologic evaluation before rapid metabolic optimization because an abrupt improvement in glycemia may temporarily accelerate its progression. Similarly, kidney disease should be assessed before conception with creatinine, albuminuria, and specialist evaluation when necessary.

Preconception medication review is equally crucial. Angiotensin-converting enzyme inhibitors (ACE inhibitors), angiotensin II receptor blockers, and statins should be discontinued before conception or as soon as pregnancy is confirmed. With regard to glucose-lowering therapy, insulin remains the cornerstone of type 1 diabetes management and is often necessary in type 2 diabetes as well. NICE permits metformin as an alternative or adjunct to insulin in selected preconception and pregnancy settings, whereas other oral medications should generally be discontinued. At this stage, it is important to remember the nosological boundary with hyperglycemia first diagnosed during pregnancy: when the condition does not represent pre-existing diabetes but develops during gestation, the appropriate reference is gestational diabetes, which has its own diagnostic criteria and screening schedule.

Once pregnancy is established, care should begin early and be jointly managed by the diabetes and obstetric teams. NICE guidelines recommend immediate contact with an integrated clinic and close follow-up, often every 1–2 weeks. Glycemic targets become tighter: fasting glucose below 5.3 mmol/L, equivalent to 95 mg/dL; 1-hour postprandial glucose below 7.8 mmol/L, equivalent to 140 mg/dL; or 2-hour postprandial glucose below 6.4 mmol/L, equivalent to 115 mg/dL. In insulin-treated patients, a safety threshold above 4 mmol/L, equivalent to 72 mg/dL, should nevertheless be maintained to reduce hypoglycemia risk. A woman with type 1 diabetes should check fasting, preprandial, postprandial, and bedtime glucose each day. The profile is similar in insulin-treated type 2 diabetes, whereas in less complex forms monitoring may focus mainly on fasting and postprandial values.

Technology has assumed an increasingly important role. In pregnancies complicated by type 1 diabetes, continuous glucose monitoring has been shown to improve time in the pregnancy-specific range and neonatal outcomes, and NICE recommendations support offering real-time continuous glucose monitoring to all pregnant women with type 1 diabetes. In insulin-treated women without type 1 diabetes, continuous monitoring may be particularly useful in the presence of severe hypoglycemia, marked glycemic instability, or difficulty reaching targets. Continuous subcutaneous insulin infusion and automated hybrid systems are also increasingly used in pregnancies complicated by type 1 diabetes, but they require teams with specific expertise, training, out-of-hours support, and the ability to interpret patterns and alarms rapidly.

Insulin requirements do not remain constant during pregnancy. In the first trimester, particularly in type 1 diabetes, insulin sensitivity may increase and hypoglycemia risk may rise. Subsequently, progressive increases in placental hormones and insulin resistance often require higher doses and frequent adjustments. Women with type 1 diabetes should be trained to recognize the risk of diabetic ketoacidosis, which can develop more rapidly during pregnancy and at glucose levels that are not necessarily extreme. Hyperglycemia, nausea, vomiting, malaise, or reduced intake should therefore prompt a low threshold for ketone testing and urgent assessment.

Pregnancy complicated by pre-existing diabetes also requires structured surveillance of maternal and fetal complications. The retina should be reassessed early in pregnancy and again during the second and third trimesters according to baseline findings. Renal status should be monitored early, with particular attention to albuminuria and kidney function, bearing in mind that standard estimated glomerular filtration rate formulas are unreliable during pregnancy. From an obstetric perspective, the 20-week fetal anomaly scan is especially important for detecting malformations, including fetal cardiac abnormalities. Fetal growth is then monitored serially, often every 4 weeks during the third trimester, to identify macrosomia, polyhydramnios, or, conversely, growth restriction in women with nephropathy or vascular disease. Pre-existing diabetes in pregnancy is therefore not simply “diabetes with a baby bump,” but a completely redefined endocrine, metabolic, and vascular state that requires continuous adaptation.

The postpartum period represents another critical transition. With placental delivery, insulin resistance falls abruptly and insulin requirements decline within hours; automatically continuing late-pregnancy doses therefore exposes the woman to significant hypoglycemia. In breastfeeding women, fragmented sleep, irregular meals, and the energy expenditure of lactation may further increase hypoglycemia risk. The postnatal period consequently requires rapid dose review, a new set of targets, and a reasoned reintroduction of therapies for comorbidities that were withheld for fetal safety. Contraceptive counseling and planning for any future pregnancies should also resume early, because postpartum does not close the issue but prepares the next phase of the clinical course.

In older adults, diabetes ceases to be a disease interpreted almost exclusively through glycated hemoglobin and pharmacological algorithms and becomes a condition closely intertwined with frailty, comorbidities, cognitive function, independence, nutritional status, fall risk, polypharmacy, and life expectancy. Treating diabetes in an older person as though it were diabetes in a young adult is one of the most common errors in clinical practice. A robust, independent, cognitively intact older adult with a long life expectancy may benefit from targets relatively close to standard values. By contrast, a person with cognitive decline, kidney failure, frailty, or dependence in activities of daily living often benefits more from a cautious strategy centered on preventing hypoglycemia, dehydration, symptoms, and hospitalization than from pursuing tight targets.

The first clinical step in diabetes care for an older adult is therefore a multidimensional assessment. The ADA Standards of Care 2026 explicitly emphasize the need to consider medical, psychological, functional, and social domains. It is not enough to know that a patient is 82 years old with an HbA1c of 7.1%. It is necessary to determine whether the patient prepares medications independently, can use pens or sensors, recognizes hypoglycemia symptoms, eats regularly, has adequate vision, has tremor or arthritis that makes self-administration difficult, lives alone, has a reliable caregiver, has intact memory, experiences depression or apathy, falls frequently, is sarcopenic or malnourished, has kidney or heart failure, can afford treatment, and can realistically manage the daily burden of care.

The central concept is that the greatest risk in an older patient is not always chronic hyperglycemia, but often overtreatment. Glucose-lowering medications that are numerically effective can become dangerous in a body with reduced counterregulatory reserve, impaired awareness of hypoglycemia, variable kidney function, inconsistent appetite, and greater neurological vulnerability. Hypoglycemia in an older person is not merely an episode to be corrected with rapidly absorbed carbohydrates: it may cause confusion, syncope, fracture, arrhythmia, an emergency department visit, delirium, loss of independence, and institutionalization. Prevention of hypoglycemia therefore carries much greater clinical weight than at other stages of life.

Modern diabetes management in older adults is founded on three key terms: individualize, simplify, and deintensify when necessary. Individualization means accepting that the same target is not appropriate for everyone. Simplification means reducing, whenever possible, the number of administrations, calculation complexity, variability in timing, the need for difficult interpretation, and the risk of error. Deintensification means reducing the dose or number of medications, or replacing high-risk drugs with safer options, when the risk–benefit balance requires it. This does not mean “neglecting” diabetes, but treating it in proportion to the person’s vulnerability.

Medication classes do not have the same profile in older adults. Sulfonylureas and, more generally, medications that nonphysiologically increase hypoglycemia risk require great caution, especially in the presence of cognitive decline, irregular meals, or impaired kidney function. Insulin is often necessary, but it should be used in the simplest and safest possible regimen. In many older adults, moving from complex regimens with multiple injections and frequent corrections to more straightforward schedules dominated by a basal component and requiring fewer daily decisions reduces risk without materially worsening clinically meaningful control. Technology, including sensors and alert systems, may also be highly beneficial, but only when it is genuinely usable by the patient or caregiver and embedded in a realistic training context.

Another decisive issue is the relationship between diabetes, cognition, and physical function. Cognitive decline reduces the ability to recognize patterns, calculate doses, remember schedules, and respond appropriately to acute events. Neuropathy, sarcopenia, and frailty increase fall risk and limit movement. Diabetes in an older adult must therefore also be treated as a functional disease. Nutrition should preserve lean mass and avoid unnecessarily severe restrictions. Physical activity should target not only glycemia but also strength, balance, the ability to stand up, walk, and remain independent. Treatment should be calibrated to the times when the patient can actually consume food and take medications regularly.

Hospital admission, entry into residential care, the development of a new comorbidity, or cognitive decline should always trigger review of the diabetes plan. During these transitions, the issue is not automatically adding treatment, but asking whether the previous regimen still makes sense. An older person with new kidney failure, poor appetite, and nocturnal hypoglycemia should not be managed through continuous correction of a number, but through protection. Diabetes in older adults is not “less important”; rather, therapeutic success more often means clinical stability, prevention of acute events, and preservation of independence than biometric perfection.

Surgery is one of the most delicate transitions for a patient with diabetes because it combines metabolic stress, changes in nutritional intake, possible dehydration, perioperative medications, infection risk, and the need to prevent both stress hyperglycemia and fasting-related hypoglycemia. In this setting, diabetes should not be treated as secondary to the procedure because perioperative glycemic control affects infectious complications, wound dehiscence, healing time, length of stay, and overall clinical stability. For this reason, recent recommendations have also defined preoperative targets more clearly.

For a patient scheduled for elective surgery, planning should begin when the patient is placed on the surgical waiting list. The ADA Standards of Care 2026 consider a preoperative HbA1c below 8% during the preceding 3 months, or analogous indicators of recent control when HbA1c is uninformative, a reasonable target for improving postoperative outcomes. This does not mean that every patient with a higher HbA1c should automatically be excluded from surgery, but a schedulable procedure provides an opportunity to optimize metabolism, review treatment, correct avoidable factors, and reach the operating room under safer conditions.

Preoperative preparation should include careful review of treatment, independence, cardiovascular risk, kidney function, autonomic neuropathy, gastroparesis, foot ulceration, previous ketoacidosis or hyperosmolar state, and the patient’s ability to manage fasting and temporary medication changes. In type 1 diabetes, one point is nonnegotiable: basal insulin must never be stopped completely, because fasting does not eliminate the risk of ketogenesis. In type 2 diabetes, the strategy should be adapted to the treatment and type of procedure, but the general principle is that medications must be modified according to fasting, kidney function, hypoglycemia risk, and the likelihood of prolonged reduced intake.

Among the medications requiring particular attention are sodium–glucose cotransporter 2 inhibitors (SGLT2 inhibitors). The risk of euglycemic ketoacidosis during fasting, surgical stress, or acute illness has led ADA recommendations to advise withholding them before scheduled procedures, generally for 3 days for most agents and 4 days for ertugliflozin. The medication should not be restarted automatically the day after surgery, but only when the patient is hemodynamically stable, adequately hydrated, has resumed eating, and has no evidence of ketosis.

On the day of surgery, the meaning of glycemic control changes. At this stage, chronic “control” matters much less than maintaining glucose within a safe range. The ADA Standards of Care 2026 indicate a perioperative target range of 100–180 mg/dL. This interval is sufficiently cautious to reduce marked hyperglycemia and infection risk, yet broad enough to avoid hypoglycemia caused by overtreatment during fasting or reduced intake. Persistently higher values, particularly when associated with clinical instability or inability to eat, require prompt adjustment and sometimes intravenous insulin in more complex settings.

After surgery, diabetes does not immediately return to its outpatient “normal.” Pain, the inflammatory response, artificial nutrition, glucocorticoids, reduced mobility, infections, and irregular resumption of eating alter insulin requirements and glycemic stability. In noncritically ill inpatients, the preferred strategy therefore remains a scheduled insulin regimen with a basal component and reasoned corrections, avoiding exclusive reliance on the old reactive sliding scale. In patients with poor or uncertain oral intake, the prandial component should be adjusted cautiously, but the objective remains to prevent hyperglycemia rather than merely pursue it after it has developed.

Perioperative technology requires explicit planning. Sensors, insulin pumps, and automated systems cannot be left solely to the patient’s usual routine without the surgical and anesthesia teams knowing how to manage them. In selected procedures and well-trained patients, it may be possible to continue the pump or part of the technological support; in other cases, a temporary transition to a different regimen is safer. The decisive factor is not the technology itself, but the existence of a shared, written protocol understood by all professionals involved.

Discharge after surgery is, finally, a phase at high risk of error. The patient may return home with reduced appetite, pain, antibiotic therapy, wound care, limited mobility, and medications that differ from those taken before admission. Without clear medication reconciliation, there is a risk of inappropriately restarting withheld drugs, omitting basal insulin, resuming an SGLT2 inhibitor too early, or continuing hospital doses that are no longer suitable at home. Perioperative diabetes care therefore does not end in the operating room but requires clinical continuity from the surgical indication through complete recovery.

Infections and intercurrent illnesses can rapidly transform diabetes from a relatively stable chronic condition into a highly variable disease with a high risk of decompensation. Fever, pneumonia, urinary tract infection, gastroenteritis, sepsis, skin infection, or even severe influenza increase the secretion of catecholamines, cortisol, glucagon, and proinflammatory cytokines, resulting in greater hepatic glucose production and worsening insulin resistance. Glucose therefore tends to rise precisely while the patient is eating less, becoming dehydrated, and more vulnerable to treatment errors. In people with type 1 diabetes, and to some extent in those taking SGLT2 inhibitors or with markedly reduced insulin reserve, the combination of insufficient insulin and acute stress can rapidly promote ketosis and ketoacidosis.

Infections should therefore not be managed according to the logic of “continue everything as usual.” They require sick-day rules, a set of adjustment principles for days of illness. The absolute cornerstone is that, in type 1 diabetes and more generally in all insulin-treated patients at risk of ketosis, basal insulin must not be discontinued even when the patient is eating very little. Fasting can be misleading in this setting: eating less may intuitively suggest drastically reducing insulin, but if illness raises counterregulatory requirements, insulin omission may be the factor that transforms a simple fever into ketoacidosis.

Alongside insulin continuity, it is necessary to increase monitoring frequency. Many practical protocols recommend checking glucose every 2–4 hours in patients who usually self-monitor or use technology, particularly in the presence of high fever, vomiting, diarrhea, reduced intake, or persistently elevated values. In type 1 diabetes and any situation carrying a risk of ketosis, blood ketones should be measured early and repeatedly when persistent hyperglycemia, nausea, abdominal pain, vomiting, or general deterioration is present. During pregnancy, the threshold for concern about ketones should be even lower.

Another priority is hydration. Many acute diabetic crises are precipitated not by glucose alone, but by the combination of hyperglycemia, osmotic polyuria, reduced fluid intake, and volume loss. A patient with intercurrent illness should be instructed to drink regularly, even in small sips when nausea limits intake, and to maintain a source of absorbable carbohydrate when solid food cannot be tolerated. In practice, the illness plan should specify not only medication doses but also which fluids, foods, or food substitutes should be used to prevent progression toward dehydration and catabolism.

Intercurrent illness also requires temporary review of some medications. Sick-day protocols and safety recommendations consistently advise temporarily withholding SGLT2 inhibitors during significant acute illness, dehydration, hospitalization for severe disease, or major surgery, and restarting only after recovery under metabolically stable conditions. Metformin may also need to be withheld temporarily in the presence of substantial vomiting, diarrhea, hypoperfusion, worsening kidney function, or risk of accumulation. Depending on the clinical situation, the team may also decide to suspend other medications that promote dehydration or functional kidney injury, but this decision must always be individualized.

The distinction between an intercurrent illness that can be “managed at home” and a situation requiring urgent assessment is essential. Several warning signs warrant a very low threshold for medical contact or urgent evaluation:

• persistent vomiting or inability to retain fluids;
• marked and persistent hyperglycemia despite appropriate correction doses;
• the presence or increase of blood ketones;
• labored breathing, drowsiness, confusion, abdominal pain, or rapid deterioration in general condition;
• high fever with signs of sepsis, hypotension, oliguria, or severe dehydration.

In patients hospitalized with an infection, diabetes requires a different approach from outpatient care. The priority becomes maintaining glucose within a safe range, managing its relationship with any glucocorticoid treatment, adapting therapy to the type of nutrition, and preventing hypoglycemia. Hospital recommendations favor scheduled, individualized insulin regimens rather than occasional corrective doses. When infection is accompanied by reduced intake, kidney failure, or steroid therapy, rapidly changing insulin requirements demand close clinical monitoring and substantial therapeutic flexibility.

Finally, vaccination prevention also belongs within the discussion of infections. Diabetes is associated with a higher risk of complications from influenza, pneumococcal disease, hepatitis B, and other vaccine-preventable infections, and vaccination recommendations should be integrated into routine follow-up. This is particularly important in older adults, patients with chronic kidney disease, people with frequent hospital admissions, and those living in residential facilities. In diabetes, infections are therefore not only events to be treated when they occur, but also events to be prevented actively and systematically.

The major error in managing diabetes in special settings is to regard them as rare exceptions to “real” diabetes care. Pregnancy, advanced age, surgical procedures, and intercurrent illnesses are in fact predictable or frequent events in the natural history of a person with diabetes. Good clinical practice therefore consists not of reacting once the event is already under way, but of preparing the patient and the team in advance. A woman of childbearing potential with diabetes should receive preconception counseling well before a pregnancy test. An older adult with increasing frailty should undergo treatment review before falls or severe hypoglycemia occur. A patient scheduled for elective surgery should reach the operating room with a written diabetes plan. Every insulin-treated person or anyone at risk of ketosis should know their sick-day rules in advance.

This anticipatory approach also changes the meaning of therapeutic education. In special settings, it is not enough for the patient to “know they have diabetes”; the patient must know what changes when the context changes. They must recognize that a high glucose value during pregnancy does not carry the same implications as the same value on an ordinary day; that hypoglycemia in an older adult may be more dangerous than mild hyperglycemia; that preoperative fasting does not justify stopping all insulin; and that vomiting and fever are not days to stop checking glucose, but days to check it more often. Medicine in special settings is therefore, to a large extent, the medicine of anticipation and interpretation.

There is also an organizational dimension that cannot be ignored. Many errors arise not from missing theoretical knowledge, but from incomplete handovers, lack of shared protocols, poor communication among specialists, imprecise discharge plans, or failure to involve the caregiver. An older person on a complex insulin regimen, a pregnant woman using continuous glucose monitoring, or a patient discharged after sepsis and steroid therapy cannot be entrusted to vague instructions. Guidance must be clear, understandable, verifiable, and adapted to the actual home setting.

In summary, special settings are not an appendix to diabetes care, but the situations in which the quality of diabetology is truly tested. When the treatment plan can change as the body, function, and risk change, management becomes genuinely individualized. More than the choice of medication alone, this is where the distinction is made between diabetes that is simply treated and diabetes that is truly managed.