What are the recommended management strategies for Type 2 Diabetes (T2D)?

Type 2 Diabetes Management Strategies

For optimal management of Type 2 Diabetes (T2D), implement a comprehensive treatment approach combining lifestyle modifications with appropriate pharmacotherapy, prioritizing metformin and SGLT2 inhibitors as first-line medications for most patients with T2D.

Lifestyle Management

Physical Activity

• Engage in at least 150 minutes per week of moderate-intensity aerobic activity, spread throughout the week 1, 2
• Include 2-3 sessions of resistance exercise on non-consecutive days weekly 1, 2
• Break up prolonged sedentary time (≥30 minutes) with brief activity 1
• For children and adolescents with T2D: aim for at least 60 minutes of moderate-to-vigorous activity daily 1

Nutrition Therapy

• Implement individualized medical nutrition therapy with a registered dietitian 2
• For overweight/obese patients: reduce caloric intake to achieve 5-10% weight loss 2, 3
• Recommended diet composition:
  • <30% total fat
  • <7-10% saturated fats
  • 45-60% carbohydrates (emphasizing vegetables, fruits, whole grains, legumes)
  • 15-20% protein

  • 15g fiber per 1000 kcal (half soluble) 2, 3

• Limit sodium intake to <2g/day for patients with CKD 1
• Limit alcohol to one drink daily for women and two for men 2

Pharmacological Management

First-Line Therapy

• Start with metformin for most patients with T2D and eGFR ≥30 mL/min/1.73m² unless contraindicated 1, 2, 4
  • Begin with low dose and gradually titrate to minimize gastrointestinal side effects
  • Monitor renal function regularly

Second-Line Therapy (Add to metformin)

• For patients with eGFR ≥30 mL/min/1.73m², add an SGLT2 inhibitor 1, 2

  • Provides cardiovascular risk reduction
  • Reduces heart failure hospitalizations
  • Slows CKD progression
  • Offers weight loss benefits
  • Has low hypoglycemia risk

• For patients unable to use metformin or SGLT2 inhibitors, or who haven't achieved glycemic targets:

  • Add a GLP-1 receptor agonist, particularly for patients needing greater glucose lowering and weight management 1, 2
  • For patients with advanced CKD (eGFR <30 mL/min/1.73m²), GLP-1 RAs are preferred for glycemic management 1

Special Situations

• Consider insulin initiation regardless of current therapy if:
  • Evidence of ongoing catabolism (unexpected weight loss)
  • Symptoms of hyperglycemia are present
  • A1C >10% or blood glucose ≥300 mg/dL 1, 2

Monitoring and Follow-up

• Assess glycemic response with HbA1c every 3-6 months 2
• Target HbA1c <7% for most patients 2
• Reevaluate medication plan every 3-6 months and adjust as needed 1
• Monitor blood pressure, lipids, weight, and kidney function regularly 2
• Consider treatment intensification if HbA1c target not achieved after 3 months on current therapy 2

Potential Pitfalls and Considerations

• SGLT2 inhibitors have rare risk of diabetic ketoacidosis and may increase risk of genital mycotic infections 2
• Hypoglycemia risk is higher with insulin and sulfonylureas 2
• Metformin should not be used in patients with severe renal impairment (eGFR <30 mL/min/1.73m²) 5
• Avoid medication inertia - regularly assess glycemic control and adjust therapy as needed 2
• Factors affecting A1C accuracy include conditions affecting red blood cell turnover 2

Cardiovascular Risk Management

• Target blood pressure <130/80 mmHg 2
• Consider statin therapy for most persons with diabetes aged 40 years or older 2
• Use ACE inhibitor or ARB (but not both) for hypertension management, particularly with albuminuria or CKD 2

By implementing these evidence-based strategies for T2D management, clinicians can effectively improve glycemic control, reduce complications, and enhance quality of life for patients with T2D.