From the Guidelines
The initial treatment approach for type 2 diabetes mellitus (T2DM) should involve lifestyle modifications combined with metformin therapy, as metformin is the preferred initial pharmacologic agent due to its efficacy, safety, and potential to reduce the risk of cardiovascular events and death 1.
Initial Treatment Approach
The treatment of T2DM should start with lifestyle modifications, including dietary changes focusing on reduced caloric intake, portion control, and limiting refined carbohydrates while increasing fiber intake. Regular physical activity of at least 150 minutes per week of moderate-intensity exercise is also recommended.
- Metformin is typically initiated at 500 mg once daily with meals, gradually increasing to 1000 mg twice daily as tolerated to minimize gastrointestinal side effects.
- For patients with HbA1c levels above 9%, or those with significant symptoms of hyperglycemia, combination therapy may be warranted from the outset, potentially including a second oral agent such as a SGLT-2 inhibitor or GLP-1 receptor agonist.
- Weight loss of 5-10% of body weight should be encouraged as it significantly improves insulin sensitivity.
Rationale for Metformin
Metformin is the preferred initial pharmacologic agent for the treatment of type 2 diabetes due to its long-established evidence base for efficacy and safety, and its potential to reduce the risk of cardiovascular events and death 1. It is also inexpensive and can be safely used in patients with an estimated glomerular filtration rate as low as 30 mL/min/1.73 m2, although the dose should be reduced in patients with declining renal function 1.
Monitoring and Adjustments
Regular blood glucose monitoring is essential to assess treatment efficacy, with target fasting glucose of 80-130 mg/dL and HbA1c below 7% for most patients. The treatment approach should be individualized based on patient characteristics, disease severity, and patient preferences, and should involve a patient-centered approach to guide the choice of pharmacologic agents 1.
From the FDA Drug Label
Initial Combination Therapy with Metformin A total of 1364 patients with type 2 diabetes participated in a double-blind, randomized, active-controlled study to evaluate the efficacy and safety of JARDIANCE in combination with metformin as initial therapy compared to the corresponding individual components Treatment-naïve patients with inadequately controlled type 2 diabetes entered an open-label placebo run-in for 2 weeks. At the end of the run-in period, patients who remained inadequately controlled and had an HbA1c between 7 and 10. 5% were randomized to one of 8 active-treatment arms: JARDIANCE 10 mg or 25 mg; metformin 1000 mg, or 2000 mg; JARDIANCE 10 mg in combination with 1000 mg or 2000 mg metformin; or JARDIANCE 25 mg in combination with 1000 mg or 2000 mg metformin. At Week 24, initial therapy of JARDIANCE in combination with metformin provided statistically significant reductions in HbA1c (p-value <0. 01) compared to the individual components
The initial treatment approach for type 2 diabetes mellitus (T2DM) can include metformin as the first-line treatment.
- JARDIANCE (empagliflozin) in combination with metformin can be used as an initial therapy for treatment-naïve patients with inadequately controlled type 2 diabetes.
- This combination has been shown to provide statistically significant reductions in HbA1c compared to the individual components 2.
- The use of JARDIANCE in combination with metformin as initial therapy is supported by clinical trials that demonstrate its efficacy and safety in patients with type 2 diabetes 2.
From the Research
Initial Treatment Approach for Type 2 Diabetes Mellitus (T2DM)
The initial treatment approach for T2DM focuses on several key areas, including:
- Intensive lifestyle intervention with at least 150 minutes per week of physical activity, weight loss with an initial goal of 7 percent of baseline weight, and a low-fat, reduced-calorie diet 3
- Aggressive management of cardiovascular risk factors, such as hypertension, dyslipidemia, and microalbuminuria, using medications like aspirin, statins, and angiotensin-converting enzyme inhibitors 3
- Normalization of blood glucose levels, with a target hemoglobin A1C level of less than 7 percent 3
Medications for T2DM
Medications play a crucial role in the treatment of T2DM, with options including:
- Metformin, which decreases hepatic glucose output and sensitizes peripheral tissues to insulin, and is considered a first-line agent 3
- Sulfonylureas and nonsulfonylurea secretagogues, alpha glucosidase inhibitors, and thiazolidinediones, which target various aspects of glucose metabolism 3
- SGLT2 inhibitors, such as empagliflozin and canagliflozin, which improve glycemic control, reduce body weight, and decrease blood pressure, and may be considered for patients with established cardiovascular disease 4
- Insulin, which can be used acutely to normalize blood glucose or added to a regimen of oral medication to improve glycemic control 3
Lifestyle Changes for T2DM
Lifestyle changes are essential for the management of T2DM, with a focus on:
- Healthy dietary changes, such as a Mediterranean dietary pattern, which can help prevent T2DM and reduce the risk of complications 5
- Regular physical activity, which can help improve glycemic control and reduce the risk of cardiovascular disease 6, 7
- Weight loss, which can help improve insulin sensitivity and reduce the risk of complications 3, 7
Monitoring and Management of T2DM
Monitoring and management of T2DM involve:
- Regular monitoring of blood glucose levels, which can help identify areas for improvement and adjust treatment plans accordingly 3
- Use of personalized diabetes management applications, such as the Diameter, which can help patients track their diet, physical activity, and glucose values, and provide tailored coaching to improve adherence to lifestyle recommendations 6
- Regular assessment of cardiovascular risk factors and adjustment of treatment plans as needed 3, 4