10 Key Management Strategies for Type 2 Diabetes Mellitus
The cornerstone of Type 2 Diabetes management is a comprehensive approach combining lifestyle modifications with appropriate pharmacotherapy, prioritizing agents with proven cardiovascular and renal benefits. 1
1. First-Line Pharmacotherapy
Metformin is the preferred first-line medication for most patients with Type 2 diabetes 2, 1
- Start at a low dose and gradually titrate to minimize gastrointestinal side effects
- Can be used in patients with eGFR ≥30 mL/min/1.73 m²
- Consider periodic testing of vitamin B12 levels in patients on long-term metformin therapy 1
For patients who cannot take metformin or have contraindications:
- Consider SGLT2 inhibitors or GLP-1 receptor agonists, especially in patients with cardiovascular or renal comorbidities 1
2. Physical Activity Recommendations
- Engage in at least 150 minutes of moderate-intensity aerobic activity weekly, spread over at least 3 days with no more than 2 consecutive days without activity 2, 1
- Perform 2-3 sessions of resistance exercise per week on non-consecutive days 2
- Include at least one set of five or more different resistance exercises involving large muscle groups 2
- Break up prolonged sitting every 30 minutes with brief activity for blood glucose benefits 2, 1
- For those with complications (especially peripheral neuropathy), proper footwear and daily foot examination are essential 2
3. Dietary Management
- No single ideal macronutrient distribution exists for all people with diabetes 1
- Dietary energy should consist of 20-30% fat and 50-65% carbohydrates 2
- Protein intake should be approximately 15-20% of total calorie intake (about 0.8 g/kg/day) 2
- 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 disease risk 1
- Limit sodium consumption to <2,300 mg/day (further restriction may be indicated for those with hypertension) 1
4. Weight Management
- For overweight or obese individuals, aim for weight loss of ≥5% through calorie reduction and lifestyle modification 2, 1
- Weight loss of >10% early in the course of diabetes increases the chance of disease remission 2
- Consider GLP-1 receptor agonists with high weight loss efficacy for patients requiring pharmacological support for weight management 2
5. Second-Line Treatment Options
- SGLT2 inhibitors or GLP-1 receptor agonists are preferred second-line options due to their cardiorenal benefits 1
- When selecting add-on therapy, consider:
- Patient characteristics (obesity, cardiovascular risk)
- Efficacy of the medication
- Risk of hypoglycemia
- Cost and patient preferences 2
- If glycemic targets are not met with dual therapy, consider triple therapy with agents having different mechanisms of action 2
6. Insulin Therapy
- Initiate insulin therapy when:
- Random blood glucose ≥250 mg/dL
- HbA1c >9%
- Patient is ketotic or in diabetic ketoacidosis 2
- Consider basal insulin with continuation of oral agents when maximum doses of oral medications fail to achieve glycemic control 2
- Monitor for hypoglycemia risk, especially when combining insulin with sulfonylureas 2
7. Monitoring and Follow-Up
- Monitor HbA1c every 3 months and intensify treatment if goals are not met 2, 1
- Individualize HbA1c targets (ranging from <6.5% to <8.0%) based on age, disease duration, comorbidities, and hypoglycemia risk 1
- Perform regular finger-stick blood glucose monitoring for patients:
- Taking insulin or medications with hypoglycemia risk
- Initiating or changing diabetes treatment
- Not meeting treatment goals
- With intercurrent illnesses 2
8. Cardiovascular Risk Reduction
- Aggressively manage cardiovascular risk factors including hypertension and dyslipidemia 2
- Prioritize SGLT2 inhibitors for patients with heart failure risk 1
- Consider GLP-1 receptor agonists for patients with established atherosclerotic cardiovascular disease 1
- Smoking cessation should be strongly encouraged for all patients with diabetes 2
9. Prevention and Management of Complications
- Perform comprehensive foot examination annually 1
- Conduct dilated eye examination annually 1
- Screen for nephropathy annually with urine albumin-to-creatinine ratio 1
- Check blood pressure at every routine visit 1
- For patients with autonomic neuropathy, exercise with caution due to increased risk of exercise-induced injury 2
10. Diabetes Self-Management Education and Support (DSMES)
- DSMES is critical to integrated, holistic, person-centered care and is as important as pharmacotherapy 2
- Initiate DSMES at diagnosis, annually, with changes in health status, and during transitions of care 2
- Address social determinants of health and mental health concerns that may impact diabetes management 2
Remember that diabetes management requires a comprehensive approach that addresses not only glycemic control but also cardiovascular risk reduction, prevention of complications, and support for self-management.