What is the classical treatment approach for type 2 diabetes?

From the Guidelines

The classical treatment approach for type 2 diabetes involves a stepwise strategy beginning with lifestyle modifications and metformin as first-line therapy. Patients are typically advised to improve their diet by reducing carbohydrate intake, increasing fiber consumption, and controlling portion sizes, alongside regular physical activity (150 minutes of moderate exercise weekly) 1. Metformin is usually started at 500 mg once or twice daily with meals, gradually increasing to a target dose of 1000-2000 mg daily in divided doses to minimize gastrointestinal side effects.

Key Considerations

• If glycemic targets (typically HbA1c <7%) are not achieved after 3 months, second-line agents are added, including sulfonylureas (like glipizide 5-20 mg daily), DPP-4 inhibitors (such as sitagliptin 100 mg daily), SGLT-2 inhibitors (empagliflozin 10-25 mg daily), or GLP-1 receptor agonists (weekly injectable semaglutide starting at 0.25 mg) 1.
• Insulin therapy is considered when oral medications fail to control blood glucose levels adequately.
• This approach targets the underlying pathophysiology of type 2 diabetes, addressing insulin resistance through metformin and lifestyle changes, while additional medications help improve insulin secretion, reduce glucose reabsorption in kidneys, or slow gastric emptying to better control postprandial glucose levels.

Treatment Goals

• The primary goal of treatment is to achieve and maintain individualized glycemic targets, which typically include an HbA1c level <7% 1.
• Comprehensive cardiovascular risk reduction must be a major focus of therapy, including management of blood pressure, lipids, and other cardiovascular risk factors 1.

Patient-Centered Approach

• All treatment decisions should be made in conjunction with the patient, focusing on his/her preferences, needs, and values 1.
• A person-centered shared decision-making approach should guide the choice of pharmacologic agents for adults with type 2 diabetes, considering the effects on cardiovascular and renal comorbidities, effectiveness, hypoglycemia risk, impact on weight, cost and access, risk for adverse reactions and tolerability, and individual preferences 1.

From the FDA Drug Label

High blood sugar can be lowered by diet and exercise, and by certain medicines when necessary.

The classical treatment approach for type 2 diabetes involves:

• Diet: to lower blood sugar
• Exercise: to lower blood sugar
• Medicines: when necessary, to lower blood sugar This approach aims to lower blood sugar to a normal level, and may include medications such as metformin 2 or pioglitazone 3.

From the Research

Classical Treatment Approach

The classical treatment approach for type 2 diabetes involves a combination of lifestyle modifications and pharmacological interventions.

• The primary goals of management are timely diagnosis and the prevention of complications 4.
• Lifestyle changes, such as high caloric intake reduction and increased exercise, are the main contributing causes of type 2 diabetes and the principal targets of intervention 4, 5, 6.
• If lifestyle changes do not yield adequate improvement, then drug treatment should be initiated (or intensified) and managed on the basis of the HbA1c fraction 4.

Pharmacological Interventions

• Metformin is recommended for initial drug treatment 4, 7.
• If metformin is contraindicated, poorly tolerated, or inadequately effective, many therapeutic alternatives and supplements are available, such as sulfonylureas and insulin 4, 7.
• Sodium-glucose co-transporter 2 (SGLT2) inhibitors have been shown to be effective as second-line therapy in patients with type 2 diabetes inadequately controlled on metformin, with benefits including reduced hypoglycemia and weight loss 7.

Lifestyle Modifications

• Lifestyle interventions, including dietary changes and increased physical activity, have been shown to significantly improve glycaemic control in type 2 diabetes patients 8, 6.
• Strategies combining individualized and group-based activities have been found to be the most effective in improving glycaemic control 8.
• Weight loss has been consistently observed to improve HbA1c levels in type 2 diabetes patients 8.