How is insulin resistance managed?

Management of Insulin Resistance

The management of insulin resistance requires a comprehensive lifestyle modification program including nutrition and physical activity as the foundation, with metformin as the first-line pharmacological agent when lifestyle changes are insufficient. 1

Lifestyle Interventions

Physical Activity

• Adults should perform at least 150 minutes/week of moderate-intensity aerobic physical activity (50-70% of maximum heart rate), spread over at least 3 days/week with no more than 2 consecutive days without exercise 2
• Include 2-3 sessions/week of resistance exercise on non-consecutive days 2
• Flexibility training and balance exercises 2-3 times/week for older adults 2
• Reduce sedentary behavior; interrupt prolonged sitting every 30 minutes 2
• Children and adolescents should engage in 60 minutes/day of moderate or vigorous physical activity 2

Nutrition

• Personalized nutrition plan emphasizing:
  • High-fiber foods, legumes, whole grains
  • Low-fat dairy products, fresh fish, lean proteins
  • Reduced refined carbohydrates and added sugars 1
• Limit sodium consumption to <2,300 mg/day 2
• Limit alcohol: no more than one drink per day for women and two drinks per day for men 2
• Target weight loss of 5-10% of body weight for overweight/obese individuals 1

Pharmacological Management

First-Line Therapy

• Metformin is the preferred initial pharmacological agent for insulin resistance 1
  • Starting dose: 500 mg daily
  • Gradually increase by 500 mg every 1-2 weeks
  • Target dose: 2000-2500 mg daily in divided doses
  • Monitor for vitamin B12 deficiency, particularly in patients with anemia 2

Second-Line Options

• Thiazolidinediones (e.g., pioglitazone) improve insulin sensitivity but may cause weight gain 1, 3
  • Initial dose: 15 or 30 mg once daily
  • May increase to maximum 45 mg once daily
  • Monitor for fluid retention and potential cardiovascular effects 3
• GLP-1 receptor agonists may benefit patients with concurrent type 2 diabetes and persistent hyperinsulinemia 1

Special Considerations

Monitoring and Follow-up

• Assess fasting insulin levels and insulin sensitivity markers after 3 months of intervention 1
• Schedule follow-up within 3 months to evaluate treatment response 1
• If target glycemic control is not achieved after 3 months, consider adding a second agent or adjusting doses 1

Comorbidity Management

• Address cardiovascular risk factors (hypertension, dyslipidemia) concurrently 1
• For hypertension management in insulin-resistant patients:
  • ACE inhibitors and calcium channel blockers are preferred first-line agents 1
  • Use diuretics cautiously as they may worsen insulin resistance 1

Common Pitfalls to Avoid

1. Therapeutic inertia: Failure to intensify treatment when targets are not met 1
2. Overtreatment: Overly aggressive management may lead to hypoglycemia in frail or elderly patients 1
3. Ignoring cardiovascular risk: Insulin resistance is an independent risk factor for atherosclerosis 1
4. Focusing solely on glucose levels: Not targeting the underlying insulin resistance may not improve long-term outcomes 1
5. Inadequate patient education: Ensure proper understanding of medication administration, hypoglycemia recognition/management, and importance of lifestyle modifications 1

Special Populations

Children and Adolescents

• For children with type 2 diabetes and insulin resistance:
  • Initiate lifestyle modification program including nutrition and physical activity 2
  • If ketotic or in diabetic ketoacidosis, or if random blood glucose ≥250 mg/dL or HbA1c >9%, insulin therapy should be initiated 2

Pregnancy

• Insulin is the preferred agent for management of diabetes in pregnancy due to lack of long-term safety data for non-insulin agents 2
• Frequent titration of insulin is required to match changing requirements throughout pregnancy 2

By implementing these evidence-based strategies, insulin resistance can be effectively managed to reduce the risk of progression to type 2 diabetes and associated complications.