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

Comprehensive Management of Diabetes

The cornerstone of diabetes management includes metformin as first-line pharmacotherapy, combined with lifestyle modifications including 150+ minutes of weekly moderate-intensity exercise, dietary improvements focusing on carbohydrate management, and regular monitoring of glycemic control. 1

Pharmacological Management

Initial Treatment

• Metformin is the first-line medication for most adults with type 2 diabetes 1
  • Provides 1.0-2.0% reduction in HbA1c
  • Weight neutral effects
  • Low risk of hypoglycemia
  • Reduces cardiovascular mortality compared to sulfonylureas
  • Cost-effective

Second-line Therapy Selection (Based on Patient Characteristics)

• For patients with heart failure or chronic kidney disease:
  • SGLT-2 inhibitors should be considered due to cardiorenal protection benefits 1
• For patients with established cardiovascular disease or high stroke risk:
  • GLP-1 receptor agonists are preferred due to cardiovascular protection and weight reduction benefits 1
• When SGLT-2 inhibitors or GLP-1 receptor agonists are not appropriate:
  • DPP-4 inhibitors offer weight neutrality and low hypoglycemia risk 1
  • Sulfonylureas are effective but have increased hypoglycemia risk and weight gain 1
  • Thiazolidinediones are effective but may cause weight gain and fluid retention 1, 2

Insulin Therapy Considerations

• Consider insulin when:
  • Random blood glucose ≥250 mg/dL
  • HbA1c >9%
  • Patient is ketotic or in diabetic ketoacidosis
  • Maximum doses of oral medications fail to achieve glycemic control 1

Lifestyle Modifications

Physical Activity

• Engage in at least 150 minutes of moderate-intensity aerobic activity weekly 1, 3
  • Spread over at least 3 days with no more than 2 consecutive days without activity
• Perform 2-3 sessions of resistance exercise per week on non-consecutive days 1
  • Include at least one set of five or more different resistance exercises involving large muscle groups
• Break up prolonged sitting every 30 minutes with brief activity 1, 4
• Exercise timing strategies for glucose management:
  • Moderate exercise 30-60 minutes before anticipated glucose peaks can blunt postmeal surges 4
  • Short-duration, high-intensity exercise can also be effective 4, 3

Dietary Recommendations

• Prioritize carbohydrates from vegetables, fruits, legumes, whole grains, and dairy products 1, 5
• Emphasize foods higher in fiber and lower in glycemic load 1
• Avoid sugar-sweetened beverages to control weight and reduce cardiovascular disease risk 1
• Consider meal composition and timing strategies:
  • Low-carbohydrate, balanced meals 4
  • Eating most carbohydrates earlier in the day 4
  • Consuming protein and vegetables first, followed by carbohydrates 30 minutes later 4
• For patients using insulin, match prandial insulin doses to carbohydrate intake 5
• For those on fixed insulin doses, maintain consistent carbohydrate intake timing and amounts 5

Weight Management

• For overweight or obese individuals, aim for weight loss of ≥5% through calorie reduction 1
• Weight loss of >10% early in diabetes increases chance of disease remission 1
• Consider GLP-1 receptor agonists for patients requiring pharmacological support for weight management 1

Monitoring and Targets

Glycemic Targets

• Individualize HbA1c targets based on:
  • Risk of complications
  • Comorbidities
  • Life expectancy
  • Patient preferences 1
• General target of <7% for most patients 1
• Monitor HbA1c every 3 months and intensify treatment if goals not met 1
• Consider deintensification when HbA1c is <6.5% 1

Additional Monitoring

• Regular blood glucose monitoring, especially for insulin users 5
• Monitor renal function regularly, especially with SGLT-2 inhibitors and metformin 1
• Assess for hypoglycemia risk, particularly with insulin or insulin secretagogues 6

Cardiovascular Risk Management

• Aggressively manage cardiovascular risk factors, including hypertension and dyslipidemia 1
• Blood pressure control according to guidelines (less than 140/90 mm Hg or less than 130/80 mm Hg for patients with diabetes) 5
• Strongly encourage smoking cessation 1
• Consider cardiovascular benefits when selecting second-line agents (prefer GLP-1 receptor agonists or SGLT-2 inhibitors over sulfonylureas) 1

Education and Support

• Provide Diabetes Self-Management Education and Support (DSMES) at diagnosis, annually, with changes in health status, and during transitions of care 1
• Refer patients for individualized Medical Nutrition Therapy (MNT), preferably provided by a registered dietitian 1
• Address social determinants of health and mental health concerns that may impact diabetes management 1

Common Pitfalls and Caveats

• Hypoglycemia risk: Metformin rarely causes hypoglycemia by itself, but risk increases with inadequate food intake, alcohol consumption, or combination with other glucose-lowering medications 6
• Exercise precautions: Special precautions are necessary for those with diabetic complications such as retinopathy or peripheral neuropathy 7
• Medication side effects:
  • Metformin may cause gastrointestinal side effects and metallic taste 6
  • Thiazolidinediones may cause weight gain and fluid retention 2
  • SGLT-2 inhibitors require monitoring of renal function 1
• Alcohol consumption: If consuming alcohol, limit to one drink per day for women and two drinks per day for men, and be aware of increased hypoglycemia risk 1

By implementing this comprehensive approach to diabetes management, focusing on appropriate pharmacotherapy, lifestyle modifications, and regular monitoring, patients can achieve optimal glycemic control and reduce the risk of diabetes-related complications.