What are the guidelines for managing type 1 and type 2 diabetes?

Comprehensive Guidelines for Managing Type 1 and Type 2 Diabetes

The management of diabetes requires an individualized, comprehensive approach that includes medical nutrition therapy, physical activity, medication, and regular monitoring to achieve optimal glycemic control and reduce complications.

Type 1 Diabetes Management

Insulin Therapy

• Initial insulin dosing: 0.4-1.0 units/kg/day, typically starting at 0.5 units/kg/day 1
• Regimen options:
  • Multiple daily injections (MDI) with 3-4 injections per day
  • Continuous subcutaneous insulin infusion (CSII/insulin pump)
• Distribution: 50% basal insulin, 50% prandial insulin 1
• Prandial insulin should be matched to carbohydrate intake, pre-meal glucose levels, and anticipated physical activity

Blood Glucose Monitoring

• Self-monitoring of blood glucose or continuous glucose monitoring (CGM) is essential 1
• Test blood glucose frequently and at critical times (before meals, after meals, before exercise, before driving) 2
• Target HbA1c < 7% for most patients, but may be individualized based on hypoglycemia risk, disease duration, and comorbidities

Hypoglycemia Management

• Learn signs and symptoms of hypoglycemia and how to manage it 2
• Always carry a source of fast-acting sugar
• Keep glucagon at home
• Wear medical alert identification 2

Type 2 Diabetes Management

Pharmacological Approach

1. First-line therapy:

   • Metformin at or soon after diagnosis, along with lifestyle therapy 1, 2
   • Start at low dose and titrate up to 2,000 mg per day as tolerated 2

2. Second-line therapy (based on comorbidities):

   • For patients with established or high risk of cardiovascular disease, heart failure, or chronic kidney disease: Add SGLT-2 inhibitor 1, 2
   • For patients with increased stroke risk or when weight loss is important: Add GLP-1 receptor agonist 1
   • For HbA1c ≥9%: Consider initial dual-combination therapy 1
   • For HbA1c ≥10% or blood glucose ≥300 mg/dL: Consider early insulin therapy 1

3. Insulin therapy (if needed):

   • Continue metformin unless contraindicated
   • GLP-1 receptor agonist is preferred to insulin when possible 1
   • If insulin is required, combination with GLP-1 receptor agonist is recommended for greater efficacy and reduced weight gain 1

Medication Adjustments for Chronic Kidney Disease

• Metformin may be given when eGFR ≥30 ml/min per 1.73 m² 2
• SGLT2i should be initiated when eGFR is ≥20 ml/min per 1.73 m² and continued until dialysis or transplantation 2

Lifestyle Management for Both Type 1 and Type 2 Diabetes

Nutrition Therapy

• An individualized medical nutrition therapy program, preferably provided by a registered dietitian, is recommended for all people with diabetes 2
• No single ideal macronutrient distribution exists; meal plans should be based on individual assessment 2
• Carbohydrate recommendations:
  • Focus on nutrient-dense sources high in fiber (vegetables, fruits, legumes, whole grains, dairy) 2
  • Avoid sugar-sweetened beverages and minimize foods with added sugars 2
  • For those on fixed insulin doses, maintain consistent carbohydrate intake regarding timing and amount 2
  • For flexible insulin therapy, use carbohydrate counting to determine mealtime insulin dosing 2
• For overweight/obese patients with type 2 diabetes, weight loss of ≥5% through calorie reduction and lifestyle modification is recommended 2

Physical Activity

• Perform at least 150 minutes per week of moderate-intensity aerobic activity or 75 minutes of vigorous-intensity physical activity 1, 3
• Include 2-3 sessions of resistance exercise on non-consecutive days weekly 1, 4
• 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

Monitoring and Follow-up

Regular Assessments

• Reevaluate medication plan every 3-6 months and adjust as needed 1
• Assess glycemic response with HbA1c every 3-6 months 1
• Monitor blood pressure, lipids, weight, and kidney function regularly 1
• Target blood pressure <130/80 mmHg 1
• Consider statin therapy for most persons with diabetes aged 40 years or older 1

Screening for Complications

• Annual dilated eye examinations starting 3-5 years after onset of type 1 diabetes 2
• Regular screening for microalbuminuria to detect early nephropathy 2
• Monitor for vitamin B12 deficiency in patients on long-term metformin (>4 years) 1

Special Considerations

Children and Adolescents with Type 2 Diabetes

• Initial treatment approach depends on symptoms, severity of hyperglycemia, and presence of ketosis/ketoacidosis 2
• Metformin is the first-line oral medication after resolution of ketosis/ketoacidosis 2
• Consider metabolic surgery for adolescents with severe obesity (BMI >35 kg/m²) and elevated A1C despite lifestyle and pharmacologic intervention 2

Cardiovascular Risk Reduction

• Maintain LDL cholesterol <100 mg/dL (2.60 mmol/L) 2
• Consider aspirin therapy for cardiovascular disease prevention 2
• Use ACE inhibitors or ARBs for hypertension management, particularly with albuminuria 2

Common Pitfalls and How to Avoid Them

1. Underestimating the importance of lifestyle modifications:

   • Lifestyle changes are the foundation of diabetes management and should be emphasized at every visit

2. Inadequate hypoglycemia prevention:

   • Educate patients and families about hypoglycemia recognition and management
   • Consider sensor-augmented low glucose threshold suspend pumps for patients with frequent nocturnal hypoglycemia 1

3. Delayed treatment intensification:

   • Don't delay adding medications when glycemic targets aren't met
   • Reassess therapy every 3-6 months and adjust as needed 1

4. Overlooking comorbidities:

   • Regularly screen for and manage cardiovascular risk factors, retinopathy, nephropathy, and neuropathy
   • Tailor medication choices to address comorbidities (e.g., SGLT2i for heart failure or CKD) 2

5. Neglecting patient education:

   • Provide diabetes self-management education at diagnosis, annually, with changes in health status, and during transitions of care 1

By following these comprehensive guidelines, healthcare providers can help patients with both type 1 and type 2 diabetes achieve optimal glycemic control and reduce the risk of diabetes-related complications.