What are the recommended treatments and lifestyle modifications for diabetes management?

Diabetes Management: Treatment and Lifestyle Modifications

For optimal diabetes management, metformin should be used as first-line therapy, followed by SGLT2 inhibitors or GLP-1 receptor agonists as second-line options, along with at least 150 minutes of moderate-to-vigorous aerobic activity per week and a diet emphasizing fiber-rich foods with a low glycemic load. 1

Pharmacological Management

First-Line Treatment

• Metformin is the optimal first-line medication for most patients with type 2 diabetes 1
  • Start at a low dose and gradually titrate to minimize gastrointestinal side effects
  • Appropriate for patients with eGFR ≥30 ml/min per 1.73 m²
  • May cause metallic taste in approximately 3% of patients when starting treatment 2
  • Periodic testing of vitamin B12 levels is recommended for patients on long-term metformin therapy 1

Second-Line Treatment Options

• SGLT2 inhibitors or GLP-1 receptor agonists are preferred second-line options due to their proven cardiorenal benefits 1
  • These medications provide cardiovascular protection and weight reduction benefits
  • GLP-1 receptor agonists are particularly beneficial for patients with established cardiovascular disease

Combination Therapy Considerations

• When combining medications, be aware of potential interactions:
  • Adding sulfonylureas to metformin and SGLT2 inhibitors increases hypoglycemia risk 1
  • When combining insulin with GLP-1 receptor agonists, reassess insulin dosing to prevent hypoglycemia 1
  • Pioglitazone can be used in combination therapy with sulfonylureas, metformin, or insulin 3

Glycemic Monitoring and Targets

• Use HbA1c to monitor glycemic control with individualized targets ranging from <6.5% to <8.0% 1
• Check HbA1c quarterly when therapy changes or targets are not met 1
• Reevaluate medication regimen every 3-6 months 1

Lifestyle Modifications

Physical Activity Recommendations

• Aerobic Exercise: At least 150 minutes of moderate-to-vigorous intensity aerobic activity per week, spread over at least 3 days with no more than 2 consecutive days without activity 1
• Resistance Training: 2-3 sessions per week on non-consecutive days, including at least one set of five or more different exercises involving large muscle groups 1
• Break Sedentary Time: Interrupt prolonged sitting every 30 minutes with brief activity for blood glucose benefits 1, 4

Dietary Recommendations

• No single ideal macronutrient distribution exists for all people with diabetes 1
• Key dietary principles:
  • Prioritize carbohydrates from vegetables, fruits, legumes, whole grains, and dairy products 1
  • Emphasize foods higher in fiber and lower in glycemic load 1
  • Avoid sugar-sweetened beverages to control weight and reduce cardiovascular risk 1
  • Consider meal timing and sequence: eating protein and vegetables before carbohydrates can moderate glucose levels 4
  • Consume most carbohydrates earlier in the day 4
  • Limit sodium to <2,300 mg/day (further restriction for those with hypertension) 1
  • If consuming alcohol, limit to one drink per day for women and two for men, being aware of increased hypoglycemia risk 1

Weight Management

• For overweight or obese individuals, aim for weight loss of ≥5% through calorie reduction and lifestyle modification 1

Special Considerations and Pitfalls

Exercise Safety Precautions

• Hypoglycemia Risk: Carefully monitor blood glucose when exercising, especially for those on insulin or insulin secretagogues 5
• Timing of Exercise:
  • Postmeal exercise (30-60 minutes after eating) can blunt glucose surges 4
  • Pre-meal exercise improves insulin sensitivity but may cause post-exertion glucose elevations 4
  • High-intensity pre-meal exercise may precipitate delayed hypoglycemia in some individuals 4

Medication-Related Considerations

• Metformin Storage: Store at 68ºF to 77ºF (20ºC to 25ºC) 2
• Pioglitazone Monitoring: Monitor for fluid retention and liver function; do not initiate if patient has active liver disease or elevated transaminases 3
• Hypoglycemia Prevention: When combining medications that increase hypoglycemia risk (especially insulin with other agents), adjust dosages appropriately 1, 3

Comprehensive Care

• Annual comprehensive foot examination 1
• Annual dilated eye examination 1
• Annual nephropathy screening with urine albumin-to-creatinine ratio 1
• Blood pressure check at every routine visit 1
• Referral for individualized Medical Nutrition Therapy, preferably provided by a registered dietitian 1

By following these evidence-based recommendations for medication management and lifestyle modifications, patients with diabetes can achieve better glycemic control and reduce the risk of diabetes-related complications.