What are the initial management steps for Diabetes Mellitus (DM)?

Initial Management of Diabetes Mellitus

The initial management of diabetes mellitus should begin with lifestyle modifications including individualized medical nutrition therapy, 150 minutes of weekly physical activity, and metformin as first-line pharmacological therapy unless contraindicated. 1

Assessment and Diagnosis Considerations

• Determine diabetes type (Type 1 vs Type 2) as management strategies differ significantly
• For patients who are ketotic, in diabetic ketoacidosis, or when distinction between Type 1 and 2 is unclear, insulin therapy should be initiated immediately 2
• Insulin therapy should also be initiated when:
  • Random blood glucose ≥250 mg/dL
  • HbA1c >9% 2, 1

Lifestyle Modifications

Nutrition Therapy

• All patients should participate in an individualized medical nutrition therapy program, preferably provided by a registered dietitian 2, 1
• Focus on:
  • Weight loss goal of 5-7% of starting weight for overweight/obese patients 1
  • Reduced total calorie intake
  • Emphasis on monounsaturated and polyunsaturated fats
  • Limiting saturated fats and avoiding trans fats 1

Physical Activity

• Recommend at least 150 minutes per week of moderate-intensity aerobic activity 2, 1
• Include resistance training at least twice weekly 1
• Reduce sedentary time throughout the day 1
• For children and adolescents, encourage 60 minutes of moderate-to-vigorous exercise daily and limit non-academic screen time to less than 2 hours per day 2

Pharmacological Management

Type 2 Diabetes

• Metformin is the preferred first-line pharmacological agent and should be initiated at or soon after diagnosis if not contraindicated 2, 1
• Benefits of metformin:
  • Inexpensive
  • Long-established evidence base for efficacy and safety
  • May reduce risk for cardiovascular events and death 2
  • Can be continued with declining renal function down to GFR of 30-45 mL/min (with dose reduction) 1

Type 1 Diabetes

• Multiple-dose insulin injections or continuous subcutaneous insulin injection is recommended 2
• Insulin analogues are preferred to reduce hypoglycemia risk 2
• Education on matching prandial insulin doses to carbohydrate intake, pre-prandial blood glucose levels, and anticipated activity level is essential 2

Special Considerations

Cardiovascular Risk Management

• For patients with established atherosclerotic cardiovascular disease, a GLP-1 receptor agonist with proven cardiovascular benefit is preferred 1
• For patients with chronic kidney disease or heart failure, an SGLT2 inhibitor with proven benefit is preferred 1

Obesity Management

• For patients with obesity, GLP-1 receptor agonists or dual GIP/GLP-1 receptor agonists are preferred for their weight loss benefits 1

Monitoring and Follow-up

• Monitor HbA1c every 3 months and intensify treatment if goals are not being met 2, 1
• Self-monitoring of blood glucose is recommended for patients:
  • Taking insulin or medications with hypoglycemia risk
  • Initiating or changing diabetes treatment regimens
  • Not meeting treatment goals
  • With intercurrent illnesses 2

Common Pitfalls to Avoid

1. Delayed intensification of therapy: Don't delay adjusting treatment when targets aren't met
2. Overbasalization with insulin: Monitor for clinical signals of excessive insulin dosing
3. Medication errors: Instruct patients to always check insulin labels before each injection to avoid mix-ups 3
4. Hypoglycemia risk: Educate patients about hypoglycemia recognition and management, especially those on insulin therapy 3
5. Neglecting cardiovascular risk factors: Regularly assess and manage cardiovascular risk factors alongside glycemic control

By following this structured approach to diabetes management, focusing on both lifestyle modifications and appropriate pharmacological therapy, patients can achieve better glycemic control and reduce the risk of diabetes-related complications.