What are the recommended treatment regimens for type 1 and type 2 diabetes?

From the Guidelines

The most effective treatment for type 1 diabetes involves insulin replacement therapy, typically through multiple daily injections or continuous subcutaneous insulin infusion via pump, as recommended by the most recent guidelines 1. For type 1 diabetes, the treatment regimen should include:

• Multiple daily injections of basal and prandial insulin or continuous subcutaneous insulin infusion (CSII) therapy
• Matching of prandial insulin to carbohydrate intake, premeal blood glucose, and anticipated activity
• Use of insulin analogs to minimize hypoglycemia risk For type 2 diabetes, treatment follows a stepwise approach, starting with:
• Lifestyle modifications
• Metformin (typically 500-2000 mg daily in divided doses) If glycemic targets are not met, additional medications can be added, such as:
• SGLT-2 inhibitors (empagliflozin, dapagliflozin)
• GLP-1 receptor agonists (semaglutide, dulaglutide)
• DPP-4 inhibitors (sitagliptin)
• Sulfonylureas (glipizide)
• Thiazolidinediones (pioglitazone) Insulin therapy may be necessary if oral medications are insufficient. The goal of treatment for both types of diabetes is to maintain blood glucose levels as close to normal as possible (typically HbA1c <7%) while minimizing hypoglycemia risk, as emphasized in recent guidelines 1. Regular monitoring of blood glucose, HbA1c levels every 3-6 months, and screening for complications are essential components of diabetes management, as highlighted in various studies 1.

Key considerations in diabetes management include:

• Individualized treatment plans
• Regular reevaluation of medication plans and medication-taking behavior
• Early combination therapy for type 2 diabetes
• Person-centered shared decision-making approach
• Consideration of cardiovascular and renal comorbidities, effectiveness, hypoglycemia risk, impact on weight, cost, and access.

By prioritizing these factors and following the most recent guidelines, healthcare providers can provide effective and personalized care for patients with diabetes, ultimately improving morbidity, mortality, and quality of life outcomes.

From the Research

Treatment Regimens for Type 1 and Type 2 Diabetes

The treatment regimens for type 1 and type 2 diabetes involve various approaches to manage blood glucose levels.

• For type 1 diabetes, insulin is the primary treatment, typically initiated with multiple daily injections at diagnosis, including short-acting or rapid-acting insulin analogue before meals and intermediate or long-acting insulin separately 2.
• The target glycated hemoglobin A1c (HbA1c) for type 1 diabetes patients is recommended to be < 7.5% (< 58 mmol/mol) 2.
• For type 2 diabetes, indications for exogenous insulin therapy include acute illness, surgery, pregnancy, glucose toxicity, and failure to achieve goals with oral antidiabetic medications 2.
• Insulin therapy in type 2 diabetes may be initiated as augmentation or replacement, with a starting dose of 0.3 unit per kg for augmentation or 0.6 to 1.0 unit per kg for replacement 3.
• The preferred method of insulin initiation in type 2 diabetes is to begin with a long-acting (basal) insulin or once-daily premixed/co-formulation insulin, alone or in combination with other oral antidiabetic drugs (OADs) 2.

Insulin Management and Titration

Insulin management and titration are crucial for achieving glycemic control in both type 1 and type 2 diabetes.

• Basal insulin is usually initiated at a conservative dose of 10 units/day or 0.1-0.2 units/kg/day and titrated based on patients' self-measured fasting plasma glucose to achieve an individualized target 4.
• The dose of basal insulin should be increased as required up to approximately 0.5-1.0 units/kg/day in some cases, while avoiding overbasalization 4.
• Biphasic insulin analogues can target both fasting and postprandial hyperglycemia and are a practical option for insulin initiation and maintenance in type 2 diabetes 5.
• Continuous subcutaneous insulin infusion (CSII) may be considered for patients with type 1 diabetes who are not meeting individual glycemic targets or experiencing frequent or severe hypoglycemia 6.

Glycemic Targets and Monitoring

Glycemic targets and monitoring are essential for effective insulin therapy.

• A glycemic target of glycated hemoglobin < 7% (53 mmol/mol) is appropriate for most nonpregnant adults with type 1 diabetes 6.
• Blood glucose monitoring is an integral part of effective insulin therapy, and fasting plasma glucose (FPG) values should be used to titrate basal insulin, while both FPG and postprandial glucose (PPG) values should be used to titrate mealtime insulin 2.
• Continuous glucose monitoring may improve glycemic control irrespective of treatment regimen 6.