What are the recommended management strategies for type 2 diabetes mellitus (T2DM)?

Management Strategies for Type 2 Diabetes Mellitus

Metformin should be initiated as the first-line pharmacological therapy for most adults with type 2 diabetes mellitus (T2DM), starting at a low dose of 500 mg daily with gradual increase by 500 mg every 1-2 weeks to a target maximum dose of 2000 mg daily in divided doses. 1

Comprehensive Approach to T2DM Management

Initial Assessment and Glycemic Targets

• Monitor HbA1c every 3 months until glycemic targets are met, then twice yearly for stable patients 1
• Individualize HbA1c targets based on patient factors with a general target of <7% for most patients 1
• For patients where HbA1c may be unreliable (advanced kidney disease), consider continuous glucose monitoring metrics 1

Pharmacological Therapy Algorithm

1. First-line therapy: Metformin (unless contraindicated)

   • Start at 500 mg daily and gradually increase to 2000 mg daily in divided doses 1
   • Monitor for gastrointestinal side effects 1
   • Contraindicated in renal insufficiency (eGFR <45 mL/min/1.73m²), liver dysfunction, severe infection, or hypoxia 1

2. Second-line therapy (if glycemic targets not met with metformin):

   • For patients with established cardiovascular disease or high CV risk: Add GLP-1 receptor agonist or SGLT-2 inhibitor with proven cardiovascular benefit 1
   • For patients with heart failure or chronic kidney disease: Add SGLT-2 inhibitor for cardiorenal protection 1
   • For patients where weight management is a priority: Consider GLP-1 receptor agonists with high weight loss efficacy 2
   • For patients where cost or hypoglycemia risk is a concern: Consider DPP-4 inhibitors 1

3. Third-line therapy and beyond:

   • If HbA1c remains >9%, consider adding basal insulin 1
   • Sulfonylureas are effective but carry increased hypoglycemia risk and weight gain 1
   • Thiazolidinediones (like pioglitazone) are effective but may cause weight gain and fluid retention 3
   • Initiate insulin therapy when random blood glucose ≥250 mg/dL, HbA1c >9%, patient is ketotic, or distinction between T1DM and T2DM is unclear 1

Lifestyle Interventions

1. Nutrition Therapy:

   • Implement individualized Medical Nutrition Therapy (MNT) for all patients 1
   • Focus on a diet high in vegetables, fruits, whole grains, fiber, legumes, plant-based proteins, unsaturated fats, and nuts; lower in processed meats, refined carbohydrates, and sweetened beverages 1
   • Prioritize carbohydrates from vegetables, fruits, legumes, whole grains, and dairy products 1
   • Dietary energy should consist of 20-30% fat, 50-65% carbohydrates, and 15-20% protein 1
   • Limit sodium intake to <2 g per day 1

2. Physical Activity:

   • Engage in at least 150 minutes of moderate-intensity aerobic activity weekly, spread over at least 3 days 1
   • Perform 2-3 sessions of resistance exercise per week on non-consecutive days 1
   • Break up prolonged sitting every 30 minutes with brief activity 1
   • For patients with complications, individualize exercise recommendations 4

3. Weight Management:

   • Target at least 5% weight loss for individuals with overweight or obesity 1
   • Substantial (>10%) weight loss early in the course of T2DM increases the chance of disease remission 2
   • Consider GLP-1 receptor agonists with high weight loss efficacy for pharmacological support of weight management 2
   • Consider metabolic surgery for those without sufficient response to non-surgical weight loss interventions 2

Cardiovascular Risk Management

• Blood pressure target of <140/90 mm Hg for patients with diabetes and hypertension 1
• Include either an ACE inhibitor or an ARB (but not both) for hypertension management 1
• Statin therapy is recommended for most persons with diabetes aged 40 years or older 1
• Strongly encourage smoking cessation 1
• Limit alcohol consumption to one drink per day for women and two drinks per day for men 1

Diabetes Self-Management Education and Support

• Provide Diabetes Self-Management Education and Support (DSMES) at diagnosis, annually, with changes in health status, and during transitions of care 2
• Establish specific, measurable, attainable, relevant, time-based (SMART) goals for behavior change 2
• Encourage self-monitoring of achievements (e.g., physical activity monitoring and weight measurement) 2

Special Considerations

• For pediatric T2DM management, follow specific guidelines including insulin therapy for ketotic states or high blood glucose 1
• For end-of-life care, focus on comfort, prevention of distressing symptoms, and preservation of quality of life and dignity 1
• Monitor renal function regularly, especially with SGLT-2 inhibitors and metformin 1

Common Pitfalls and Caveats

• Avoid an "all or none" approach to behavioral goals; any improvement in healthy behaviors can positively impact diabetes 2
• Be aware of increased hypoglycemia risk when using insulin or insulin secretagogues, especially with alcohol consumption 1
• SGLT2 inhibitors may cause an initial modest reduction in eGFR that is hemodynamic and reversible; this is generally not a reason to discontinue therapy 1
• Metformin may cause gastrointestinal side effects; starting at a low dose and gradually increasing can improve tolerance 5
• When using pioglitazone, monitor for adverse events related to fluid retention 3

By following this comprehensive management approach, patients with T2DM can achieve improved glycemic control, reduced risk of complications, and enhanced quality of life.