What are the recommended management strategies for Diabetes Mellitus (DM)?

Comprehensive Management Strategies for Diabetes Mellitus

The optimal management of diabetes mellitus requires implementing the Chronic Care Model with six core elements: delivery system design, self-management support, decision support, clinical information systems, community resources, and health systems, along with a team-based approach including physicians, nurses, pharmacists, dietitians, and other healthcare providers 1.

Pharmacological Management

First-Line Therapy

• Metformin should be initiated as first-line therapy for most patients with type 2 diabetes at diagnosis, alongside comprehensive lifestyle modifications, unless contraindicated 1, 2
  • Efficacy: 1.0-2.0% HbA1c reduction
  • Hypoglycemia risk: Low
  • Weight effect: Neutral
  • Cost: Low
  • Can be continued with declining renal function down to a GFR of 30-45 mL/min (with dose reduction) 2

Second-Line Therapy

When monotherapy with metformin at maximum tolerated dose doesn't achieve or maintain HbA1c target over 3 months, add a second agent based on patient factors 2:

• For patients with established cardiovascular disease or high risk: SGLT2 inhibitors or GLP-1 receptor agonists with proven cardiovascular benefit 1
• For patients with BMI ≥27 kg/m² requiring weight loss: Consider GLP-1 receptor agonists (semaglutide, liraglutide) 1
• Other options include:
  • Sulfonylureas (high efficacy, high hypoglycemia risk, moderate weight gain, low cost)
  • Thiazolidinediones (high efficacy, low hypoglycemia risk, weight gain, high cost)
  • DPP-4 inhibitors (intermediate efficacy, low hypoglycemia risk, weight neutral, high cost)
  • SGLT2 inhibitors (moderate efficacy, low hypoglycemia risk, weight loss, high cost)

Third-Line Therapy

• Add a third agent with a different mechanism of action if dual therapy is insufficient 1
• Options include:
  • Metformin + Sulfonylurea + Thiazolidinedione/DPP-4 inhibitor/GLP-1 receptor agonist/Basal insulin
  • Metformin + SGLT2 inhibitor + GLP-1 receptor agonist/Sulfonylurea/DPP-4 inhibitor/Basal insulin

Insulin Therapy

• Most patients with type 1 diabetes should receive multiple-dose insulin injections or continuous subcutaneous insulin infusion 2
• For type 2 diabetes requiring insulin, when initiating insulin with pioglitazone, start at 15-30 mg daily 3
• In patients receiving pioglitazone and insulin, the insulin dose can be decreased by 10-25% if hypoglycemia occurs or if plasma glucose falls below 100 mg/dL 3

Lifestyle Modifications

Nutrition Therapy

• All patients should receive individualized medical nutrition therapy, preferably from a registered dietitian 2, 1
• For gestational diabetes, provide adequate calorie intake based on National Academy of Medicine recommendations 2
• Nutrition plan should include:
  • Minimum 175g carbohydrate (35% of 2,000-calorie diet)
  • Minimum 71g protein
  • 28g fiber 2
  • Emphasis on monounsaturated and polyunsaturated fats
  • Limited saturated fats and avoidance of trans fats 2
  • Energy deficit of 500-750 kcal/day for weight loss 1
  • 2-3 servings of plant stanols/sterols (2g) daily to lower LDL cholesterol 1
  • At least 2 servings of fish weekly 1

Physical Activity

• Prescribe at least 150 minutes of moderate-intensity aerobic activity per week 2, 1
• Include resistance training at least twice weekly 2, 1
• Reduce sedentary time with walking breaks throughout the day 1
• For patients with gestational diabetes, exercise interventions (20-50 min/day, 2-7 days/week) have shown improvements in glucose outcomes 2

Weight Management

• Target initial weight loss of 3-7% of baseline weight, with greater weight loss (>10%) providing additional benefits including potential diabetes remission 1
• Monitor weight at least every 3 months during active weight management 1
• Evaluate weight loss at 3 months; consider alternative approach if <5% weight loss is achieved with medications 1

Monitoring and Evaluation

Glycemic Targets

• Monitor HbA1c every 3 months until target is reached, then at least every 6 months 1
• Individualize HbA1c targets (generally <7.0%) based on patient factors 1
• For gestational diabetes, target:
  • Fasting glucose <95 mg/dL (<5.3 mmol/L)
  • One-hour postprandial glucose <140 mg/dL (<7.8 mmol/L)
  • Two-hour postprandial glucose <120 mg/dL (<6.7 mmol/L) 2
• Consider post-prandial glucose monitoring (target <180 mg/dL) if pre-prandial levels are in range but A1C remains elevated 1

Hypoglycemia Management

• Educate patients on situations that increase hypoglycemia risk (fasting, exercise, sleep) 2
• For patients with hypoglycemia unawareness, increase glycemic targets temporarily to reverse the condition 2
• Modify treatment regimens for severe or frequent hypoglycemia 2

Complication Screening

• Annual dilated eye examinations (starting 3-5 years after onset of type 1 diabetes) 1
• Regular screening for microalbuminuria to detect early nephropathy 1
• Target blood pressure <130/80 mm Hg 1
• Daily aspirin regimen for patients with established CVD 1

Self-Management Education and Support

Patient Empowerment

• All patients should participate in diabetes self-management education and support 2, 4
• Use empowering language that is neutral, nonjudgmental, strength-based, respectful, and person-centered 2
• Focus on problem-solving skills for all aspects of diabetes management 1
• Assess patients' self-efficacy, which is related to improved diabetes self-management and treatment outcomes 2

Team-Based Care

• Implement interprofessional collaboration with clear roles 1
• Include care management teams (nurses, dietitians, pharmacists) to support patients 1
• Regular follow-up visits should assess medication adherence, side effects, laboratory evaluation, screening for complications, and treatment plan adjustments 1

Special Considerations

Gestational Diabetes

• 70-85% of people diagnosed with gestational diabetes under Carpenter-Coustan criteria can manage with lifestyle modification alone 2
• Insulin is the first-line agent for gestational diabetes requiring medication in the U.S. 2
• Metformin and glyburide are not recommended as first-line treatments due to placental crossing and concerns about long-term safety for offspring 2

Therapeutic Inertia

• Avoid therapeutic inertia (failure to intensify treatment when indicated) by prioritizing timely therapy intensification 1
• Address poor medication adherence, which accounts for 23% of cases with uncontrolled metrics 1

Pitfalls and Caveats

• Avoid overly aggressive glycemic targets in patients with advanced disease or those at high risk for hypoglycemia 2
• Monitor for fluid retention when initiating or increasing the dose of pioglitazone 3
• Pioglitazone should not be initiated in patients with active liver disease or increased transaminase levels (ALT >2.5 times upper limit of normal) 3
• Metformin exposure during pregnancy for gestational diabetes has been associated with higher BMI and increased obesity in offspring at 4-9 years of follow-up 2
• Sulfonylureas cross the placenta and have been associated with increased neonatal hypoglycemia 2