What are the guidelines for managing type 2 diabetes?

Guidelines for Managing Type 2 Diabetes

The cornerstone of type 2 diabetes management is metformin combined with an SGLT-2 inhibitor or GLP-1 agonist, alongside lifestyle modifications including individualized medical nutrition therapy and at least 150 minutes of moderate-intensity aerobic exercise weekly. 1

Pharmacological Management

First-line Therapy

• Metformin is the first-line pharmacological therapy for most patients with type 2 diabetes 2
  • Indicated as an adjunct to diet and exercise
  • Decreases hepatic glucose output and sensitizes peripheral tissues to insulin

Second-line Therapy

• Add an SGLT-2 inhibitor or GLP-1 agonist when glycemic control is inadequate with metformin alone 1
  • SGLT-2 inhibitors: Prioritize for patients with heart failure or chronic kidney disease
    • Benefits: Reduces all-cause mortality, major adverse cardiovascular events, CKD progression, and heart failure hospitalizations
  • GLP-1 agonists: Prioritize for patients with increased stroke risk or when weight loss is a treatment goal
    • Benefits: Reduces all-cause mortality, major adverse cardiovascular events, and stroke
• DPP-4 inhibitors are NOT recommended as add-on therapy 1

Glycemic Targets

• Target HbA1c between 7% and 8% for most adults 1
• Deintensify treatment when HbA1c is below 6.5%
• Individualize goals based on:
  • Hypoglycemia risk
  • Life expectancy
  • Diabetes duration
  • Established vascular complications
  • Major comorbidities
  • Patient preferences

Lifestyle Management

Nutrition Therapy

• Individualized medical nutrition therapy (MNT) is recommended for all patients 1
• Weight loss of ≥5% is beneficial for overweight/obese patients 1
• Key dietary recommendations:
  • No single ideal macronutrient distribution exists
  • Emphasize carbohydrates from vegetables, fruits, legumes, whole grains, and dairy
  • Focus on foods higher in fiber and lower in glycemic load
  • Avoid sugar-sweetened beverages
  • Minimize foods with added sugars
  • Consider Mediterranean-style diet rich in monounsaturated and polyunsaturated fats

Physical Activity

• Minimum 150 minutes of moderate-to-vigorous aerobic exercise weekly 1
  • Spread over at least 3 days per week
  • Avoid more than 2 consecutive days without exercise
• Resistance training at least twice weekly on non-consecutive days 1
  • Focus on major muscle groups
  • Perform 1-4 sets at moderate to vigorous intensity
• Flexibility exercises may complement other exercise types but should not replace them 1
• Combined aerobic and resistance exercise in the same session is recommended 1

Comprehensive Management Approach

Monitoring

• Self-monitoring of blood glucose may be unnecessary for patients on metformin plus SGLT-2 inhibitor or GLP-1 agonist 1
• More intensive monitoring needed for patients on insulin or sulfonylureas

Cardiovascular Risk Management

• Aggressive management of cardiovascular risk factors is essential:
  • Hypertension
  • Dyslipidemia
  • Microalbuminuria

Collaborative Care

• Implement collaborative care plans that include:
  • Dietary improvement and weight management
  • Sleep health
  • Physical activity
  • Stress management
  • Management of comorbidities and medications
• Involve clinical pharmacists to reduce polypharmacy risks 1

Special Considerations

Medication Adjustments

• When adding SGLT-2 inhibitor or GLP-1 agonist results in adequate glycemic control:
  • Reduce or discontinue sulfonylureas or long-acting insulins to decrease hypoglycemia risk 1

Cost Considerations

• Discuss medication costs with patients
• Prescribe generic medications when available 1

Social Determinants of Health

• Assess social risk factors
• Connect patients with social and community services as needed 1

Pitfalls to Avoid

• Relying solely on lifestyle modifications without appropriate medication
• Using DPP-4 inhibitors as add-on therapy when SGLT-2 inhibitors or GLP-1 agonists would be more beneficial
• Setting overly aggressive glycemic targets (below 6.5%) which may increase hypoglycemia risk
• Failing to adjust medications when glycemic targets are achieved
• Neglecting cardiovascular risk factor management
• Not considering patient preferences, comorbidities, and social determinants of health