What are the guidelines for managing type 2 diabetes?

Guidelines for Managing Type 2 Diabetes

The management of type 2 diabetes requires a comprehensive strategy focused on reducing risks of disease progression and cardiovascular complications through lifestyle modifications, self-management education, and appropriate pharmacological interventions. 1

First-Line Therapy

Lifestyle Interventions

• Diet recommendations:

  • Individualized diet high in vegetables, fruits, whole grains, fiber, legumes, plant-based proteins, unsaturated fats, and nuts 1
  • Lower intake of processed meats, refined carbohydrates, and sweetened beverages 1
  • Protein intake of 0.8 g/kg/day for those not on dialysis 1
  • Sodium intake <2 g per day 1

• Physical activity:

  • At least 150 minutes per week of moderate-intensity physical activity 1
  • Include both aerobic and resistance training for maximal benefits 2
  • Break up prolonged sitting with short activity breaks 2, 3
  • Afternoon and post-meal exercise may yield better glycemic benefits 3

Pharmacological Therapy

• First-line medications:

  1. Metformin for patients with eGFR ≥30 ml/min per 1.73 m² 1, 4

     • Start at low dose (500 mg daily) and gradually increase to target dose of 2000 mg daily 4

  2. SGLT2 inhibitors for patients with eGFR ≥20 ml/min per 1.73 m² 1

     • Should be initiated when eGFR is adequate and continued as tolerated until dialysis or transplantation 1

Second-Line and Additional Therapy

• If glycemic targets not achieved with first-line therapy:

  • Add a GLP-1 receptor agonist 1
  • Long-acting GLP-1 RAs are preferred for patients who haven't achieved targets with metformin and SGLT2i 1

• Insulin therapy indications:

  • When A1C ≥10-12%
  • Blood glucose ≥300-350 mg/dL
  • Symptomatic hyperglycemia
  • Evidence of catabolism
  • Ketosis/ketoacidosis 4
  • Begin with basal insulin (0.1-0.2 units/kg/day) 4

Glycemic Monitoring and Targets

• Monitoring:

  • Use HbA1c to monitor glycemic control 1
  • Regular monitoring every 3-6 months to assess medication adherence and adjust therapy 4

• Targets:

  • Individualized HbA1c target ranging from <6.5% to <8.0% based on patient factors 1
  • Consider age, comorbidities, risk of hypoglycemia, and disease duration when setting targets 1

Cardiovascular and Renal Risk Reduction

• Blood pressure management:

  • ACE inhibitor or ARB for patients with diabetes, hypertension, and albuminuria 1
  • Titrate to highest approved dose that is tolerated 1

• Lipid management:

  • Statin therapy recommended for all patients with type 2 diabetes 1

• Additional risk factor control:

  • Smoking cessation 1
  • Antiplatelet therapy for those with established cardiovascular disease 1

Special Considerations

Chronic Kidney Disease

• SGLT2 inhibitors have demonstrated kidney protection and should be prioritized 1
• Adjust medication doses based on eGFR 1
• Monitor renal function regularly 1

Weight Management

• Consider weight effects of medications:
  • Weight neutral or promoting weight loss: metformin, SGLT2 inhibitors, GLP-1 RAs 4
  • May cause weight gain: sulfonylureas, thiazolidinediones, insulin 4, 5

Hypoglycemia Risk

• All sulfonylureas can produce severe hypoglycemia 5
• Higher risk in elderly, debilitated, malnourished patients, and those with adrenal or pituitary insufficiency 5
• May be difficult to recognize in elderly and those taking beta-blockers 5

Structured Education and Support

• Implement a structured self-management educational program 1
• Provide ongoing diabetes education and support 4
• Explain the progressive nature of type 2 diabetes regularly to patients 4
• Consider team-based, integrated care focused on risk evaluation and patient empowerment 1

Medication Safety Considerations

• Metformin: Contraindicated with significant renal insufficiency 4
• Insulin: Risk of hypoglycemia, requires monitoring, may cause weight gain 6
• Sulfonylureas: Risk of hypoglycemia, weight gain, may have reduced effectiveness over time (secondary failure) 5
• SGLT2 inhibitors: Monitor for urinary tract infections, genital mycotic infections, and volume depletion 1

By following these evidence-based guidelines, healthcare providers can effectively manage type 2 diabetes and reduce the risk of complications while improving patients' quality of life.