What are the recommended treatment regimens for type 1 and type 2 diabetes?

Recommended Treatment Regimens for Type 1 and Type 2 Diabetes

Type 1 Diabetes Management

Insulin therapy is the primary treatment for all patients with type 1 diabetes mellitus (T1DM) and should be initiated immediately upon diagnosis with multiple daily injections. 1

Insulin Regimen Options:

• Multiple Daily Injections (MDI):

  • Rapid-acting insulin analogs (0-15 minutes before meals)
  • One or more daily injections of intermediate or long-acting insulin
  • Target HbA1c < 7.5% for all patients including children 1

• Continuous Subcutaneous Insulin Infusion (CSII/Insulin Pump):

  • Provides 24-hour adjustable basal insulin rate
  • Patient-activated mealtime bolus doses
  • Eliminates need for periodic injections 2

• Alternative Option: Two or three premixed insulin injections per day 1

Monitoring:

• Regular blood glucose monitoring is essential
• Use both fasting plasma glucose (FPG) and postprandial glucose (PPG) values
• Consider continuous glucose monitoring systems to avoid hypoglycemia and reduce glucose variability 1

Dosing:

• Initial insulin dosage ranges from 0.25 to 1.0 U per kg per day 3
• Adjust based on daily blood glucose patterns, physical activity, and pubertal status 2

Type 2 Diabetes Management

First-Line Therapy:

• Metformin at or soon after diagnosis, along with lifestyle therapy 4
  • Benefits include improved glycemic control, weight neutrality, reduced cardiovascular risk, and low cost

Stepped Approach:

1. Lifestyle modifications:

   • Individualized nutrition therapy focusing on nutrient-dense foods
   • 150 minutes of moderate-intensity exercise weekly plus resistance training
   • Weight management targeting 5-7% weight loss if overweight 4

2. Oral medications:

   • If HbA1c ≥ 7.5%, consider adding medications
   • When HbA1c ≥ 10%, insulin is essential even with optimized diet, physical activity, and other agents 1

3. Insulin initiation options:

   • Add long-acting (basal) insulin
   • Once-daily premixed/co-formulation insulin
   • Twice-daily premixed insulin
   • Can be combined with GLP-1 receptor agonists or oral antidiabetic drugs 1

Special Considerations for Insulin in T2DM:

• Indications: acute illness, surgery, pregnancy, glucose toxicity, failure to achieve goals with oral medications 1
• Metformin should be continued when starting insulin (decreases weight gain, lowers insulin dose, reduces hypoglycemia) 1
• Do not abruptly discontinue oral medications when starting insulin (risk of rebound hyperglycemia) 1

SGLT2 Inhibitors:

• Should be initiated when eGFR is ≥20 ml/min per 1.73 m²
• Continue until dialysis or transplantation
• Especially beneficial for patients with established or high risk of atherosclerotic cardiovascular disease, heart failure, or chronic kidney disease 4

Medication Combinations and Effectiveness

Pioglitazone (ACTOS) Effectiveness:

• As monotherapy: Reduces HbA1c by 0.6-1.9% depending on dosage
• With sulfonylurea: Reduces HbA1c by 0.9-1.67% and FPG by 39-58 mg/dL
• With metformin: Reduces HbA1c by 0.8-1.01% and FPG by 38-50.7 mg/dL
• With insulin: Reduces HbA1c by 0.7-1.46% and FPG by 35-49 mg/dL 5

Monitoring and Follow-up

• Reevaluate medication plan every 3-6 months
• Target HbA1c < 7% for most patients
• Monitor blood pressure, lipids, weight, and kidney function regularly
• Regular screening for cardiovascular risk factors, retinopathy, nephropathy, and neuropathy 4

Insulin Administration Best Practices

• Use shortest needles (4-mm pen and 6-mm syringe needles) for safety and comfort
• Avoid intramuscular injections, especially with long-acting insulins (risk of severe hypoglycemia)
• Rotate injection sites to prevent lipohypertrophy which distorts insulin absorption 1

Common Pitfalls and How to Avoid Them

• Hypoglycemia risk: Use analogue insulin (less postprandial hyperglycemia and delayed hypoglycemia)
• Rebound hyperglycemia: Don't abruptly discontinue oral medications when starting insulin
• Inadequate monitoring: Ensure patients understand glucose monitoring importance
• Lipohypertrophy: Teach proper site rotation techniques
• Renal function decline: Monitor renal function regularly, especially with SGLT-2 inhibitors and metformin

Patient Education

• Provide diabetes self-management education at diagnosis, annually, with changes in health status, and during transitions of care
• Develop sick-day plans and teach warning signs of hypoglycemia and diabetic ketoacidosis
• Consult registered dietitian-nutritionist for personalized nutrition planning 4