What is the treatment for diabetic mellitus (Diabetes Mellitus)?

Treatment of Diabetes Mellitus

The treatment of diabetes mellitus requires a comprehensive approach with different strategies for type 1 and type 2 diabetes, with insulin therapy being essential for type 1 diabetes while metformin is the preferred first-line agent for type 2 diabetes. 1

Type 1 Diabetes Management

Insulin Therapy

• Most patients with type 1 diabetes should be treated with multiple daily injections (MDI) of both prandial and basal insulin or with continuous subcutaneous insulin infusion (CSII) 1
• Rapid-acting insulin analogs are recommended to reduce hypoglycemia risk 1
• Starting total daily insulin dose is typically weight-based:
  • 0.4-1.0 units/kg of body weight
  • 0.5 units/kg for metabolically stable patients
  • Higher doses may be needed for diabetic ketoacidosis or during puberty 1

Insulin Administration Methods

• Multiple daily injections (MDI) or insulin pump therapy (CSII)
• CSII has shown slightly better HbA1c control compared to MDI (difference of -0.30 percentage points) 1
• Continuous glucose monitoring (CGM) significantly reduces severe hypoglycemia risk 1

Education and Monitoring

• Education on matching prandial insulin doses to:
  • Carbohydrate intake
  • Pre-meal blood glucose levels
  • Anticipated physical activity 1
• Patients who have mastered carbohydrate counting should learn fat and protein gram estimation 1

Type 2 Diabetes Management

Lifestyle Modifications

• Foundation of all diabetes treatment:
  • At least 150 minutes of moderate-intensity aerobic activity per week
  • Resistance training at least twice weekly
  • Reduced sedentary time 1
  • Weight loss of at least 5% for overweight/obese patients 1
  • Individualized medical nutrition therapy by a registered dietitian 1

Pharmacologic Therapy

First-Line Therapy

• Metformin is the preferred initial pharmacologic agent due to:
  • Efficacy (reduces HbA1c by approximately 1.4%) 2
  • Safety profile
  • Low cost
  • Potential cardiovascular benefits 1
  • Can be continued with declining renal function down to GFR of 30-45 mL/min (with dose reduction) 1

Second-Line Therapy

When monotherapy with metformin at maximum tolerated dose doesn't achieve or maintain HbA1c target over 3 months, add a second agent based on patient factors:

1. Patients with established cardiovascular disease or high CV risk:

   • SGLT-2 inhibitors or GLP-1 receptor agonists with proven CV benefit 3

2. Patients with chronic kidney disease:

   • SGLT-2 inhibitors (growing evidence for renoprotection) 3, 4

3. Patients with heart failure:

   • SGLT-2 inhibitors 3

4. Patients where cost is a major issue:

   • Sulfonylureas (but note higher hypoglycemia risk and weight gain) 1, 3

5. Patients where weight loss is a priority:

   • GLP-1 receptor agonists 3

Triple Therapy and Beyond

• If dual therapy doesn't achieve glycemic targets after 3 months, add a third agent from a different class 1
• Consider initiating insulin therapy when HbA1c is significantly elevated (>9%) 3
• For severely uncontrolled hyperglycemia (HbA1c >10-12%), consider starting with insulin therapy 3

Insulin in Type 2 Diabetes

• Start with basal insulin (10 units or 0.1-0.2 units/kg) 1
• Titrate based on fasting blood glucose levels
• Add prandial insulin if basal insulin alone is insufficient
• Consider starting with basal-bolus insulin when blood glucose levels are ≥300-350 mg/dL or HbA1c ≥10% 1

Glycemic Targets

General Targets

• Target HbA1c <7% for most adults 1
• More stringent targets (HbA1c <6.5%) may be appropriate for:
  • Short duration of diabetes
  • Long life expectancy
  • No significant cardiovascular disease 1

Less Stringent Targets

• Less stringent HbA1c goals (<8%) for:
  • History of severe hypoglycemia
  • Limited life expectancy
  • Advanced complications
  • Extensive comorbidities
  • Long-standing diabetes with difficulty achieving control 1
  • Older adults with multiple comorbidities or functional dependence 1

Special Populations

Older Adults

• For healthy older adults with few comorbidities: HbA1c target <7.0-7.5% 1, 3
• For older adults with multiple comorbidities or functional limitations: HbA1c target <8.0-8.5% 1, 3
• For end-of-life care: focus on comfort, symptom control, and quality of life rather than strict glycemic control 1

Pediatric Type 2 Diabetes

• Metformin is the only FDA-approved medication for children with type 2 diabetes 5
• Prevention through lifestyle modification is critical 5

Cardiovascular Risk Management

• Blood pressure target: <140/90 mmHg (<130/80 mmHg for those with chronic kidney disease) 1, 3
• Lipid management with statins based on cardiovascular risk 3
• Consider ACE inhibitors for renoprotection 3
• Limit sodium intake to 1200-2300 mg/day 1

Common Pitfalls to Avoid

• Delayed intensification of therapy leading to prolonged hyperglycemia 3
• Overbasalization with insulin causing hypoglycemia 3
• Neglecting weight effects of medications 3
• Ignoring comorbidities that could influence medication choice 3, 4
• Aggressive glycemic control in patients with advanced disease or high hypoglycemia risk 1

Hypoglycemia Management

• Treat with 15-20g of rapid-acting glucose
• Confirm reversal with blood glucose testing after 15 minutes
• Repeat treatment if hypoglycemia persists 1
• For patients with hypoglycemia unawareness, temporarily increase glycemic targets 1

The treatment of diabetes requires ongoing monitoring, education, and adjustment of therapy to achieve and maintain glycemic targets while minimizing risks of complications, particularly hypoglycemia.