What is the recommended approach for managing diabetes?

Comprehensive Approach to Diabetes Management

Metformin should be the first-line pharmacological therapy for most patients with type 2 diabetes, combined with lifestyle modifications including diet, exercise, and weight management, while SGLT2 inhibitors or GLP-1 receptor agonists should be added for patients with established cardiovascular disease, heart failure, or chronic kidney disease. 1, 2

Glycemic Targets

• Standard HbA1c target of <7.0% for most non-pregnant adults 1
• More stringent targets (<6.5%) for selected patients without significant hypoglycemia risk 1
• Less stringent targets (<8.0-8.5%) for older adults with complex health issues, limited life expectancy, or history of severe hypoglycemia 1
• Monitor A1C every 3 months after treatment changes until target is achieved 1

Initial Management Approach

Lifestyle Modifications (First-line for all patients)

• Structured self-management education program 2
• Regular physical activity (150 minutes of moderate-intensity activity weekly) 1
• Dietary modifications with consistent carbohydrate intake, emphasis on complex carbohydrates 1
• Weight management with target of 5-10% weight loss for patients with BMI >25 kg/m² 1

Pharmacological Therapy

For Type 2 Diabetes:

1. First-line: Metformin 1, 2, 3

   • Start with 500 mg once or twice daily with meals
   • Gradually titrate to effective dose (typically 2000 mg/day in divided doses)
   • Benefits: Weight neutral, low hypoglycemia risk, cardiovascular benefits (36% reduction in all-cause mortality) 3
   • Monitor for GI side effects; consider extended-release formulation if GI intolerance occurs 4

2. Second-line (if HbA1c target not achieved after 3 months):

   • For patients with established cardiovascular disease, heart failure, or CKD: 2, 1

     • Add SGLT2 inhibitor with proven cardiovascular benefit
     • Or GLP-1 receptor agonist with proven cardiovascular benefit

   • For patients without cardiovascular disease:

     • Add agent based on patient-specific factors:
       • Weight concerns: GLP-1 receptor agonist or SGLT2 inhibitor
       • Cost concerns: Sulfonylurea
       • Hypoglycemia concerns: DPP-4 inhibitor, SGLT2 inhibitor, or GLP-1 receptor agonist

3. Third-line and beyond:

   • Combination therapy with agents from different classes
   • Consider insulin therapy for severely uncontrolled diabetes (A1c ≥10%) 1

For Type 1 Diabetes:

• Multiple daily injections of basal and prandial insulin or insulin pump therapy 1
• Initial dosing: 0.1-0.2 units/kg per meal, adjusted based on carbohydrate intake, pre-meal glucose, and anticipated activity 1

Special Considerations

Cardiovascular Risk Management

• Blood pressure target: <140/90 mmHg (<130/80 mmHg for those with CKD) 1
• Statin therapy based on cardiovascular risk assessment 1
• SGLT2 inhibitors should be used in patients with heart failure as they improve heart failure and kidney outcomes 2

Chronic Kidney Disease

• For patients with CKD and eGFR ≥20 ml/min/1.73 m² and UACR >30 mg/g, an SGLT2 inhibitor should be initiated 2
• If SGLT2 inhibitor is not tolerated, a GLP-1 RA with proven cardiovascular benefit should be considered 2

Prediabetes Management

• Intensive diet and physical activity behavioral counseling targeting 7% weight loss 1
• Metformin may be considered, especially for those with BMI >35 kg/m², age <60 years, history of gestational diabetes, or progressive hyperglycemia 2, 1

Monitoring and Follow-up

• Self-monitoring of blood glucose:
  • Multiple daily checks for patients on insulin therapy 2, 1
  • Less frequent monitoring for those on non-insulin therapies 2
• Regular assessment for diabetes complications:
  • Retinopathy screening
  • Nephropathy screening
  • Neuropathy assessment
  • Cardiovascular risk assessment

Team-Based Approach

• Implement team-based, integrated care focused on risk evaluation and patient empowerment 2
• Team may include physicians, nurse practitioners, physician assistants, nurses, dietitians, pharmacists, and mental health professionals 2

Common Pitfalls to Avoid

1. Delaying intensification of therapy when glycemic targets are not met
2. Overlooking cardiovascular and renal benefits of newer agents (SGLT2i, GLP-1 RA) in appropriate patients
3. Failing to adjust medications during acute illness (follow sick day rules) 2
4. Not considering drug-specific contraindications:
   • Metformin: Avoid in severe renal impairment, dehydration, or risk of lactic acidosis 5, 6
   • SGLT2 inhibitors: Risk of dehydration and diabetic ketoacidosis during illness 2
5. Neglecting comprehensive care beyond glycemic control (blood pressure, lipids, weight management)

By following this comprehensive approach to diabetes management, focusing on individualized glycemic targets and appropriate medication selection based on comorbidities, patients can achieve optimal outcomes with reduced risk of complications.