What are the recommendations for managing diabetes mellitus type 2?

Management of Type 2 Diabetes Mellitus

The cornerstone of type 2 diabetes management is a combination of metformin as first-line pharmacotherapy, lifestyle modifications including diet and exercise, and regular monitoring with appropriate therapy escalation based on glycemic control. 1

Initial Approach

First-Line Therapy

• Metformin should be initiated at diagnosis unless contraindicated 1
  • Start with a low dose and gradually titrate to minimize gastrointestinal side effects
  • Provides effective glucose lowering with low hypoglycemia risk
  • Associated with reduced mortality in patients with type 2 diabetes 2
  • Monitor renal function regularly as metformin is contraindicated in severe renal impairment

Lifestyle Modifications

Physical Activity

• Implement at least 150 minutes per week of moderate-intensity aerobic physical activity 1, 3
  • Distribute over at least 3 days with no more than 2 consecutive days without activity
  • Include resistance training three times weekly (if no proliferative retinopathy) 3
  • Regular exercise improves glycemia, decreases insulin resistance, and reduces cardiovascular risk factors 3, 4
  • A meta-analysis showed that mild to moderate intensity aerobic exercise significantly improves HbA1c in patients with type 2 diabetes 4

Nutrition Therapy

• Individualized medical nutrition therapy (MNT) provided by a registered dietitian 1
• Focus on reducing energy intake for overweight/obese patients 3
• Aim for minimum weight loss of 5-10% of body weight 1
• Reduce intake of saturated and trans fatty acids, cholesterol, and sodium 3
• Choose carbohydrates from vegetables, fruits, whole grains, legumes, and dairy products 1
• Avoid sugar-sweetened beverages 1
• If consuming alcohol, limit to one drink per day for women and two for men 3

Monitoring and Follow-up

• Assess glycemic response with HbA1c every 3-6 months 1, 5
  • Target HbA1c < 7% for most patients
  • HbA1c reflects glycemia over the past 2-3 months
• Monitor blood pressure, lipids, weight, and kidney function regularly 1
• Self-monitoring of blood glucose is important for patients on insulin or medications with hypoglycemia risk 1

Treatment Escalation

When to Intensify Therapy

• Evaluate treatment effectiveness every 3-6 months 1
• Consider treatment intensification if:
  • HbA1c target not achieved after 3 months on current therapy
  • Evidence of ongoing catabolism
  • Symptoms of hyperglycemia
  • A1C >10% or blood glucose ≥300 mg/dL 1

Second-Line Options

1. GLP-1 receptor agonists (GLP-1 RAs)

   • Preferred for patients needing greater glucose lowering and weight management 1
   • Provide cardiovascular benefits

2. SGLT2 inhibitors

   • Recommended for patients with heart failure or chronic kidney disease 1
   • Provide cardiovascular risk reduction and slow CKD progression
   • Have low hypoglycemia risk but may increase risk of genital mycotic infections

3. Thiazolidinediones (e.g., Pioglitazone)

   • Can be initiated at 15 or 30 mg once daily 5
   • Monitor for fluid retention and avoid in patients with active liver disease 5

4. Sulfonylureas

   • Effective but carry higher hypoglycemia risk 1

Insulin Therapy

• Consider insulin if there is:
  • Evidence of ongoing catabolism
  • Symptoms of hyperglycemia
  • A1C >10% or blood glucose ≥300 mg/dL 1
• Starting dose typically 0.4-1.0 units/kg/day 1
• Basal insulin should account for 30-50% of total daily insulin requirements 1
• GLP-1 RA is preferred to insulin when possible 1
• If insulin is used, combination with GLP-1 RA provides greater glycemic effectiveness, beneficial effects on weight, and lower hypoglycemia risk 1

Cardiovascular Risk Management

• Target blood pressure <130/80 mmHg 1
• Consider statin therapy for most persons with diabetes aged 40 years or older 1
• Use ACE inhibitor or ARB (but not both) for hypertension management 1
• Aspirin therapy for secondary prevention in those with established cardiovascular disease 1

Patient Education and Support

• Provide diabetes self-management education at diagnosis, annually, with changes in health status, and during transitions of care 1
• Educate on matching prandial insulin doses to carbohydrate intake, premeal glucose levels, and anticipated physical activity 1

Common Pitfalls to Avoid

1. Medication inertia - Failure to intensify therapy when glycemic targets are not met leads to prolonged hyperglycemia 1
2. Hypoglycemia risk - Particularly high with insulin and sulfonylureas; use insulin analogs when possible to reduce risk 1
3. Overreliance on supplements - Insufficient evidence for efficacy of herbs and supplements in diabetes management 3
4. Inadequate monitoring - Regular assessment of glycemic control and complications is essential 1
5. Neglecting comorbidities - Aggressive management of cardiovascular risk factors is crucial 1

By implementing this comprehensive approach to diabetes management with appropriate medication selection, lifestyle modifications, and regular monitoring, patients with type 2 diabetes can achieve improved glycemic control and reduced risk of complications.