What are effective ways to lower blood glucose levels?

Effective Ways to Lower Blood Glucose

Lifestyle modifications combined with metformin should be initiated concurrently at diagnosis as the first-line approach to lower blood glucose levels in type 2 diabetes. 1

First-Line Interventions

Lifestyle Modifications

• Physical Activity:

  • Engage in at least 150 minutes per week of moderate-intensity aerobic activity 1, 2
  • Include 2-3 sessions of resistance exercise on non-consecutive days 1
  • Break up prolonged sedentary periods (>30 minutes) with brief activity 1

• Dietary Changes:

  • Follow a diet high in vegetables, fruits, whole grains, fiber, legumes, plant-based proteins, and unsaturated fats 2
  • Reduce intake of processed meats, refined carbohydrates, and sweetened beverages 2
  • Aim for initial weight loss of 7% of baseline weight 2
  • Target approximately 1500 kcal/day with fat limited to 30-35% of total energy 2

Pharmacological Therapy

• Metformin:
  • Start at diagnosis concurrently with lifestyle intervention 1
  • Begin with low dose (500 mg once or twice daily) and gradually increase to minimize GI side effects 1, 3
  • Maximum effective dose up to 1000 mg twice daily (often 850 mg twice daily) 1
  • Monitor for vitamin B12 deficiency with long-term use 1
  • Contraindicated in patients with eGFR <30 mL/min/1.73 m² 1, 2

Second-Line Interventions (When A1C Remains Above Target)

Additional Medications Based on Patient Characteristics:

1. For patients with heart failure or CKD:

   • SGLT2 inhibitors (if eGFR ≥20 mL/min/1.73 m²) 1, 2

2. For patients with weight management goals:

   • GLP-1 receptor agonists 1, 2
   • Dual GIP and GLP-1 receptor agonist (tirzepatide) 1

3. For patients with cost concerns:

   • Sulfonylureas (with caution regarding hypoglycemia risk) 1

4. For severely uncontrolled diabetes:

   • Insulin therapy when A1C >10% (>86 mmol/mol) or blood glucose ≥300 mg/dL (≥16.7 mmol/L), or when symptoms of hyperglycemia are present 1, 2

Special Considerations

Severely Uncontrolled Diabetes

• For patients with fasting glucose >250 mg/dL, random glucose consistently >300 mg/dL, A1C >10%, or presence of symptoms (polyuria, polydipsia, weight loss):
  • Insulin therapy in combination with lifestyle intervention is the treatment of choice 1
  • After glucose levels decrease and symptoms resolve, oral agents can be added and insulin potentially withdrawn 1

Hypoglycemia Prevention

• When adding new glucose-lowering medications, reassess and potentially reduce doses of medications with higher hypoglycemia risk (sulfonylureas, meglitinides, insulin) 1
• Treat hypoglycemia (glucose <70 mg/dL) with 15-20g of rapid-acting carbohydrate 2
• Metformin rarely causes hypoglycemia by itself but can occur if combined with other medications, insufficient food intake, or alcohol consumption 3

Monitoring and Follow-up

• Check A1C every 3 months until target is reached, then at least every 6 months 1
• Adjust interventions if A1C remains above individualized target 1
• Consider post-prandial glucose monitoring (target <180 mg/dL) if pre-prandial levels are in range but A1C remains elevated 1

Common Pitfalls to Avoid

1. Therapeutic inertia - Delaying intensification of therapy when targets aren't met 1
2. Overbasalization with insulin - Can lead to weight gain and hypoglycemia 1
3. Concurrent use of DPP-4 inhibitors with GLP-1 RAs - Provides no additional glucose-lowering benefit 1
4. Neglecting lifestyle modifications - Even with medication, lifestyle changes remain fundamental 1, 4
5. Ignoring patient preferences and barriers - Can lead to poor adherence 2

Recent evidence shows that 35.3% of patients with mild to moderately uncontrolled type 2 diabetes can achieve significant improvement in HbA1c levels through lifestyle modification alone over just 3 months 4, highlighting the importance of emphasizing these interventions alongside pharmacological approaches.