What is the treatment for type 2 diabetes?

Treatment of Type 2 Diabetes

Metformin should be the first-line pharmacological therapy for most patients with type 2 diabetes, along with comprehensive lifestyle modifications including diet, exercise, and weight management. 1

Initial Treatment Approach

Lifestyle Modifications

• Nutrition Therapy:

  • Focus on nutrient-dense foods, with carbohydrates from vegetables, fruits, legumes, whole grains, and low-fat dairy
  • Consider Mediterranean-style diet rich in monounsaturated and polyunsaturated fats
  • Avoid sugar-sweetened beverages and minimize added sugars 2

• Physical Activity:

  • Prescribe ≥150 minutes/week of moderate-to-vigorous aerobic activity spread over at least 3 days/week
  • Include 2-3 sessions/week of resistance exercise on non-consecutive days
  • Break up prolonged sitting every 30 minutes 2

• Weight Management:

  • Target 5-7% weight loss if overweight/obese through calorie reduction 2

Pharmacological Therapy

First-Line Therapy

• Metformin:
  • Start at diagnosis unless contraindicated
  • Effective, safe, inexpensive, and reduces risk of microvascular complications, cardiovascular events, and death
  • Begin with low dose (500 mg once or twice daily) and gradually titrate to reduce gastrointestinal side effects
  • Can be used safely with eGFR ≥30 mL/min/1.73 m² 1
  • Monitor vitamin B12 levels periodically due to risk of deficiency 1

When to Initiate Insulin Regardless of Other Therapies

• When symptoms of hyperglycemia are present
• When A1C >10% (>86 mmol/mol)
• When blood glucose >300 mg/dL (>16.7 mmol/L) 1

Treatment Intensification

When A1C is ≥1.5% above individualized glycemic goal or when metformin monotherapy fails:

Second-Line Options (to add to metformin)

1. SGLT-2 inhibitors (e.g., empagliflozin):

   • Preferred for patients with established atherosclerotic cardiovascular disease, heart failure, or chronic kidney disease
   • Can be initiated when eGFR is ≥20 ml/min per 1.73 m² and continued until dialysis or transplantation
   • Provides cardiovascular and renal benefits beyond glucose control 1, 3

2. GLP-1 receptor agonists:

   • Preferred for patients with established cardiovascular disease or high cardiovascular risk
   • Provides significant weight loss and cardiovascular benefits
   • More effective than insulin when possible 1

3. Sulfonylureas:

   • Effective and inexpensive but associated with weight gain and hypoglycemia risk 1

4. Thiazolidinediones:

   • Effective for glycemic control but associated with weight gain, fluid retention, and potential heart failure risk 1

5. DPP-4 inhibitors:

   • Weight neutral with low hypoglycemia risk but less potent than other options
   • Not recommended for concurrent use with GLP-1 RAs 1

Selection Factors for Second-Line Therapy

Consider the following when selecting a second agent:

• Presence of cardiovascular or renal disease
• Hypoglycemia risk
• Effects on body weight
• Side effect profile
• Cost and access
• Patient preferences 1

Monitoring and Follow-up

• Reevaluate medication plan every 3-6 months and adjust as needed
• Monitor blood pressure, lipids, weight, and kidney function regularly
• Screen for complications including retinopathy, nephropathy, and neuropathy 2

Important Considerations

Medication Adjustments

• When initiating new glucose-lowering medications, reassess the need for medications with higher hypoglycemia risk (sulfonylureas, insulin)
• Consider deprescribing or dose reduction to minimize hypoglycemia risk 1

Combination Therapy

• Early combination therapy may be considered at treatment initiation to extend time to treatment failure 1
• Do not combine DPP-4 inhibitors with GLP-1 RAs due to lack of additional benefit 1

Special Populations

• For older adults, consider more conservative glycemic targets to reduce hypoglycemia risk
• For patients with chronic kidney disease, adjust medication doses appropriately and consider SGLT-2 inhibitors for renoprotection 1

Common Pitfalls to Avoid

1. Delaying treatment intensification when glycemic targets are not met
2. Overlooking cardiovascular and renal benefits of newer agents (SGLT-2 inhibitors, GLP-1 RAs)
3. Failing to monitor for vitamin B12 deficiency with long-term metformin use
4. Not considering medication costs and access when prescribing
5. Overbasalization with insulin (signs include basal dose >0.5 IU/kg/day, high bedtime-morning glucose differential, hypoglycemia) 1

By following this structured approach to type 2 diabetes management, clinicians can effectively control hyperglycemia while reducing the risk of complications and improving patient outcomes.