From the Guidelines
The American Diabetes Association's current standards of care for type 2 diabetes prioritize individualized treatment approaches, combining lifestyle modifications and medication therapy, with metformin as the preferred initial pharmacologic agent, and consideration of SGLT2 inhibitors or GLP-1 receptor agonists for patients with established atherosclerotic cardiovascular disease, heart failure, or chronic kidney disease, as recommended in the 2022 guidelines 1.
Key Recommendations
- Initial management includes lifestyle changes (medical nutrition therapy, physical activity, and weight management) alongside metformin as first-line pharmacotherapy, typically starting at 500 mg daily and titrating to 1000 mg twice daily as tolerated.
- For patients with established atherosclerotic cardiovascular disease, heart failure, or chronic kidney disease, adding a GLP-1 receptor agonist (like semaglutide, dulaglutide) or SGLT-2 inhibitor (empagliflozin, dapagliflozin, canagliflozin) is recommended, as supported by the 2022 ADA and KDIGO guidelines 1.
- Treatment intensification should occur every 3-6 months if glycemic targets aren't met, with A1C goals typically 7% for most adults but potentially more relaxed (8%) for older adults with multiple comorbidities.
Medication Therapy
- Metformin is the preferred initial pharmacologic agent for the treatment of type 2 diabetes, due to its effectiveness, safety, and potential to reduce the risk for cardiovascular events and death 1.
- SGLT2 inhibitors, such as empagliflozin, dapagliflozin, and canagliflozin, are recommended for patients with established atherosclerotic cardiovascular disease, heart failure, or chronic kidney disease, due to their demonstrated cardiovascular benefits 1.
- GLP-1 receptor agonists, such as semaglutide and dulaglutide, are also recommended for patients with established atherosclerotic cardiovascular disease, heart failure, or chronic kidney disease, due to their demonstrated cardiovascular benefits 1.
Monitoring and Follow-up
- Regular monitoring includes quarterly A1C testing until target is reached, annual screening for complications (retinopathy, nephropathy, neuropathy), and ongoing cardiovascular risk assessment.
- The 2022 ADA guidelines emphasize the importance of individualized treatment approaches and regular monitoring to optimize glycemic control and prevent diabetes-related complications 1.
From the Research
Current Standards of Care for Type 2 Diabetes
The American Diabetes Association (ADA) recommends the following standards of care for type 2 diabetes:
- Lifestyle management, including diet and physical activity, as the foundation of treatment 2, 3, 4, 5, 6
- Metformin as the first-line pharmacologic agent for type 2 diabetes, due to its efficacy, safety, and cost-effectiveness 3, 4, 6
- Consideration of SGLT2 inhibitors or GLP-1 receptor agonists as second-line therapy, particularly for patients with established cardiovascular disease or at high risk for cardiovascular events 2, 3, 4, 5
- Use of DPP-4 inhibitors or sulfonylureas as alternative second-line therapies, although they may not offer the same level of cardiovascular protection as SGLT2 inhibitors or GLP-1 receptor agonists 3, 4
Pharmacologic Treatment Options
The following pharmacologic agents are commonly used to treat type 2 diabetes:
- SGLT2 inhibitors: reduce glucose reabsorption in the kidney, promoting glucose excretion in the urine, and have been shown to reduce the risk of major adverse cardiovascular events and heart failure 2, 3, 4, 5
- GLP-1 receptor agonists: mimic the action of the incretin hormone GLP-1, enhancing glucose-dependent insulin secretion and reducing glucagon levels, and have been shown to reduce the risk of major adverse cardiovascular events and weight 2, 3, 4, 5, 6
- DPP-4 inhibitors: inhibit the enzyme DPP-4, which breaks down GLP-1, allowing GLP-1 to remain active for longer periods, and have been shown to reduce HbA1c levels 3, 4, 6
- Sulfonylureas: stimulate insulin release from the pancreas, but may increase the risk of hypoglycemia and weight gain 3, 4
Cardiovascular and Renal Outcomes
The use of SGLT2 inhibitors and GLP-1 receptor agonists has been associated with improved cardiovascular and renal outcomes, including: