What is the step-by-step approach for treating diabetes?

Step-by-Step Approach for Treating Diabetes

The step-by-step approach for treating diabetes should follow a person-centered shared decision-making process that considers cardiovascular and renal comorbidities, effectiveness, hypoglycemia risk, impact on weight, cost, and patient preferences. 1

Initial Therapy for Type 2 Diabetes

1. First-line therapy:

   • Metformin should be started at diagnosis unless contraindicated 1
   • Begin with low dose and gradually titrate to minimize gastrointestinal side effects 2
   • Comprehensive lifestyle modifications should be implemented concurrently, not as isolated treatment 2

2. Lifestyle modifications:

   • At least 150 minutes of moderate-intensity aerobic activity weekly
   • 2-3 sessions of resistance exercise per week
   • Individualized medical nutrition therapy focusing on non-starchy vegetables, whole fruits, legumes, whole grains, nuts/seeds
   • Aim for 7-10% weight loss if overweight/obese 2

Treatment Intensification

1. Medication plan re-evaluation:

   • Assess every 3-6 months 1
   • Intensify treatment promptly if not meeting glycemic targets 1
   • Consider early combination therapy to shorten time to goal attainment 1

2. Selection of second-line agents:

   • For patients with established cardiovascular disease or high CV risk:
     • Add SGLT2 inhibitor or GLP-1 receptor agonist with proven cardiovascular benefit 1
   • For patients with heart failure:
     • SGLT2 inhibitor is recommended regardless of A1C 1
   • For patients with CKD (eGFR 20-60 mL/min/1.73m²):
     • SGLT2 inhibitor to minimize CKD progression 1
   • For patients with advanced CKD (eGFR <30 mL/min/1.73m²):
     • GLP-1 RA is preferred for glycemic management 1
   • For patients without CV/renal disease:
     • Select agents based on individualized glycemic and weight goals 1

3. Third-line therapy:

   • Add additional agent from a different class based on patient-specific factors
   • Consider triple therapy if dual therapy insufficient

Insulin Initiation

1. When to consider insulin:

   • Regardless of background therapy if:
     • Evidence of ongoing catabolism (unexpected weight loss)
     • Symptoms of hyperglycemia present
     • A1C >10% or blood glucose ≥300 mg/dL 1

2. Insulin strategy:

   • GLP-1 RA is preferred to insulin when possible 1
   • If insulin is used, combine with GLP-1 RA for greater effectiveness, beneficial effects on weight, and lower hypoglycemia risk 1
   • Reassess insulin dosing upon addition or dose escalation of GLP-1 RA 1
   • Typical starting insulin dose: 0.5 units/kg/day (50% basal, 50% prandial) 1

Monitoring and Follow-up

1. Regular monitoring:
   • A1C at least twice yearly for stable patients, quarterly if not meeting targets
   • Blood pressure, lipids, weight, and kidney function
   • Initial and ongoing laboratory evaluation including lipid profile, microalbuminuria, serum creatinine 2

Special Considerations

1. Hypoglycemia management:

   • Treat with 15-20g glucose or carbohydrates
   • Recheck after 15 minutes and repeat if necessary
   • Prescribe glucagon for those at significant risk of severe hypoglycemia 2

2. De-escalation of therapy:

   • Consider in specific situations:
     • After significant weight reduction
     • With declining renal function
     • In elderly patients with comorbidities 3

Common Pitfalls to Avoid

• Clinical inertia: Failure to intensify therapy when appropriate leads to suboptimal glycemic control 4
• Overbasalization with insulin: Watch for signs including basal dose >0.5 IU/kg/day, hypoglycemia, or high glycemic variability 1
• Neglecting cardiovascular risk management: Aggressively manage hypertension and dyslipidemia alongside glucose control 2
• Overlooking vitamin B12 deficiency: Monitor in patients on long-term metformin therapy 1

This algorithm provides an evidence-based approach to diabetes management that prioritizes cardiovascular and renal outcomes while considering individual patient factors and preferences.