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

Guidelines for Diabetes Management

For optimal diabetes management, metformin should be the first-line medication for type 2 diabetes, while SGLT-2 inhibitors or GLP-1 receptor agonists should be added when glycemic control is inadequate, with medication selection based on cardiovascular and renal risk factors. 1, 2

Type 2 Diabetes Management

First-Line Approach

• Lifestyle modifications: Foundation of all diabetes management

  • Nutrition: Individualized medical nutrition therapy focusing on nutrient-dense foods, appropriate portions, and carbohydrates from vegetables, fruits, legumes, whole grains 2
  • Physical activity: ≥150 minutes/week of moderate-to-vigorous aerobic activity spread over at least 3 days/week, plus 2-3 sessions/week of resistance exercise 2
  • Weight management: Initial goal of 7% reduction from baseline weight 2

• Pharmacological therapy:

  • Metformin is first-line therapy due to effectiveness, safety, low cost, and ability to reduce microvascular complications, cardiovascular events, and mortality 2
  • Monitor vitamin B12 levels periodically in patients on metformin, particularly those with anemia or peripheral neuropathy 2

Second-Line Therapy (When Glycemic Control is Inadequate)

• Add an SGLT-2 inhibitor when:

  • Patient has congestive heart failure (CHF) or chronic kidney disease (CKD) 1
  • Goal is to reduce risk for all-cause mortality, major adverse cardiovascular events, progression of CKD, and hospitalization due to CHF 1

• Add a GLP-1 receptor agonist when:

  • Patient has increased risk for stroke 1
  • Weight loss is an important treatment goal 1
  • Goal is to reduce risk for all-cause mortality, major adverse cardiovascular events, and stroke 1

• Avoid adding DPP-4 inhibitors to metformin and lifestyle modifications (strong recommendation; high-certainty evidence) 1

Glycemic Targets and Monitoring

• Aim for HbA1c levels between 7% and 8% in most adults with type 2 diabetes 1
• Deintensify pharmacologic treatments in adults with HbA1c levels less than 6.5% 1
• Reevaluate medication plan every 3-6 months and adjust as needed 2
• Self-monitoring of blood glucose might be unnecessary in patients receiving metformin combined with either an SGLT-2 inhibitor or a GLP-1 agonist 1

Cardiovascular Risk Management

• Regular screening for and managing cardiovascular risk factors is essential 2
• Use ACE inhibitors or ARBs for hypertension management, particularly with albuminuria, with target blood pressure <130/80 mmHg 2
• Maintain LDL cholesterol <100 mg/dL (2.60 mmol/L) 2
• Consider aspirin therapy for cardiovascular disease prevention 2

Type 1 Diabetes Management

• Insulin therapy: Essential for all patients with type 1 diabetes

  • Insulin aspart (MERILOG) can be used as part of a regimen with intermediate- or long-acting insulin 3
  • Inject subcutaneously within 5–10 minutes before meals 3
  • Rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis 3
  • Never share insulin pens, needles, or syringes between patients 3

• Lifestyle considerations:

  • Same physical activity recommendations as type 2 diabetes: ≥150 minutes/week of moderate-to-vigorous aerobic activity plus resistance training 2
  • Individualized nutrition therapy is crucial 2

Common Pitfalls and Considerations

• Medication adjustments:

  • When adding an SGLT-2 inhibitor or GLP-1 agonist results in adequate glycemic control, reduce or discontinue existing treatment with sulfonylureas or long-acting insulins to reduce risk for severe hypoglycemia 1
  • Sulfonylureas and long-acting insulins are inferior to SGLT-2 inhibitors and GLP-1 agonists in reducing all-cause mortality and morbidity 1

• Hypoglycemia risk:

  • Hypoglycemia is the most common adverse reaction of all insulins 3
  • Risk factors include changes in meal pattern, physical activity level, or concomitant medications 3
  • Patients with renal or hepatic impairment may be at higher risk 3
  • Educate patients and caregivers to recognize and manage hypoglycemia 3

• Medication errors:

  • Accidental mix-ups between insulin products have been reported 3
  • Instruct patients to always check the insulin label before each injection 3

• Comprehensive approach:

  • Collaborative care plans should include integrated efforts with dietary improvement, weight management, sleep health, physical activity, stress management, and management of comorbidities 1
  • Provide diabetes self-management education at diagnosis, annually, with changes in health status, and during transitions of care 2