What is the management of adults with newly diagnosed Diabetes Mellitus (DM)?

From the Guidelines

Management of adults with newly diagnosed diabetes mellitus should prioritize a patient-centered approach, incorporating lifestyle modifications and, when necessary, medication, with metformin being the preferred initial pharmacologic agent for type 2 diabetes, as evidenced by the 2016 American Diabetes Association standards of medical care in diabetes 1.

Lifestyle Modifications

Key components of lifestyle modifications include:

• A physical activity plan with at least 150 minutes of moderate-intensity aerobic activity per week, reduced sedentary time, and resistance training at least twice per week for most adults with diabetes 1.
• Dietary changes, with the recommendation for all persons with diabetes to work with a dietitian 1.
• Weight management, aiming for a loss of at least 5% of body weight for those who are overweight or obese.

Medication for Type 2 Diabetes

For type 2 diabetes, metformin therapy is recommended as the initial pharmacologic agent, if tolerated and not contraindicated, due to its efficacy, safety, and potential to reduce the risk of cardiovascular events and death 1. The dosage of metformin should be gradually increased to minimize gastrointestinal side effects, typically starting at 500mg once or twice daily and increasing to 1000mg twice daily as tolerated.

Management of Type 1 Diabetes

For type 1 diabetes, insulin therapy is essential from diagnosis, with most patients benefiting from multiple-dose insulin injections or continuous subcutaneous insulin injection 1. The use of insulin analogues can help reduce the risk of hypoglycemia 1. Continuous glucose monitoring systems and insulin pump therapy with a low blood glucose level "suspend" feature can also significantly reduce severe hypoglycemia risk 1.

Ongoing Care

Regular screening for complications should begin at diagnosis, including:

• Eye examination to detect diabetic retinopathy.
• Foot examination to assess for neuropathy and vascular disease.
• Kidney function tests to monitor for nephropathy.
• Cardiovascular risk assessment to identify and manage factors contributing to macrovascular disease.

From the FDA Drug Label

ACTOS is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. The management of antidiabetic therapy should be individualized. Ideally, the response to therapy should be evaluated using HbA1c which is a better indicator of long-term glycemic control than FPG alone.

The management of adults with newly diagnosed diabetes mellitus should start with diet and exercise.

• Pioglitazone (PO) can be used as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus.
• The response to therapy should be evaluated using HbA1c, which is a better indicator of long-term glycemic control than FPG alone 2, 2.

From the Research

Management of Adults with Newly Diagnosed Diabetes Mellitus

• The management of type 2 diabetes mellitus (T2DM) involves lifestyle modifications to achieve better control of diabetes, as the etiology of T2DM involves a complex interplay between genetics and environmental factors 3.
• Initial management goals for newly diagnosed diabetes patients include control of hyperglycemia, correction of fluid and electrolyte imbalances, and avoidance of hypoglycemia 4.
• For patients with type 2 diabetes, standard therapy begins with dietary modifications, exercise, and an oral hypoglycemic agent if needed, while insulin is indicated during times of acute stress, infection, surgery, and pregnancy, or if the patient is allergic to sulfonylureas 4.

Treatment Strategies

• The 2017 American Association of Clinical Endocrinologists and the American College of Endocrinology clinical practice guidelines provide updates on the initial treatment of T2DM, including changes and additions regarding psychosocial management, physical activity, surgery, and hypoglycemia 5.
• Good glycemic control with metformin may reduce overall mortality in obese patients with type 2 diabetes, and improved blood pressure control reduced diabetes-related mortality 6.
• Control of hypertension, LDL cholesterol, and smoking cessation can reduce major cardiovascular events in patients with type 2 diabetes 6.

Patient Education and Support

• Patients with newly diagnosed diabetes only need to have a basic understanding of glucose monitoring, medications, diet, and symptoms of hypoglycemia initially, and therapy can become more intensive as the patient learns more about diabetes and the treatment regimen 4.
• Simultaneous control of diabetes mellitus, hypertension, and hyperlipidemia is uncommon and generally transient, but less stringent goals can have a relatively large effect on the proportion achieving simultaneous control 7.