What is the comprehensive treatment plan for diabetes type 2 and its complications, including lifestyle modifications and pharmacological interventions?

Comprehensive Treatment Plan for Type 2 Diabetes and Its Complications

A comprehensive treatment plan for type 2 diabetes should include lifestyle modifications, pharmacological therapy with metformin as first-line treatment, and the addition of SGLT2 inhibitors or GLP-1 receptor agonists for patients with cardiovascular or kidney disease, along with regular monitoring and management of complications. 1

Lifestyle Modifications

• Implement individualized medical nutrition therapy with caloric restriction to achieve weight loss goals of 7-10% of excess body weight in overweight/obese patients 1
• Engage in regular physical activity (at least 150 minutes per week of moderate-intensity exercise) to improve glycemic control and reduce cardiovascular risk factors 1, 2
• Provide comprehensive diabetes self-management education to support lifestyle changes and medication adherence 1
• Consider structured weight management programs, including behavioral therapy for patients not meeting weight goals 1
• For patients with severe obesity, consider metabolic surgery as an appropriate intervention when lifestyle and pharmacological interventions are insufficient 1

Pharmacological Management

Initial Therapy

• Start metformin at diagnosis unless contraindicated, as it is effective, safe, inexpensive, and may reduce cardiovascular events and mortality 1
• Consider early combination therapy to shorten time to attainment of glycemic goals and extend time to treatment failure 1
• Initiate insulin regardless of background therapy if there is evidence of ongoing catabolism (weight loss), symptoms of hyperglycemia, or very high A1C (>10%) or blood glucose (≥300 mg/dL) 1

Subsequent Therapy Based on Comorbidities

• For patients with cardiovascular disease:

  • Add an SGLT2 inhibitor or GLP-1 receptor agonist with proven cardiovascular benefit, independent of A1C levels 1
  • For heart failure (with reduced or preserved ejection fraction), prioritize SGLT2 inhibitors for glycemic management and prevention of heart failure hospitalizations 1

• For patients with chronic kidney disease:

  • With eGFR 20-60 mL/min/1.73 m² and/or albuminuria, use an SGLT2 inhibitor to minimize CKD progression and reduce cardiovascular events 1
  • With advanced CKD (eGFR <30 mL/min/1.73 m²), prefer GLP-1 receptor agonists for glycemic management and cardiovascular event reduction 1

• For patients without cardiovascular/kidney disease:

  • Select agents that address both glycemic and weight goals 1
  • When insulin is needed, combination with a GLP-1 receptor agonist (including dual GIP and GLP-1 receptor agonists) is recommended for better glycemic control and beneficial effects on weight 1
  • GLP-1 receptor agonists are generally preferred to insulin when possible 1

Monitoring and Treatment Adjustments

• Reevaluate medication plan and medication-taking behavior every 3-6 months 1
• Adjust therapy based on glycemic control, weight goals, presence of comorbidities, hypoglycemia risk, and patient preferences 1
• Do not delay treatment intensification when glycemic targets are not met 1
• Monitor for complications regularly through appropriate screening tests 3

Management of Complications

Cardiovascular Complications

• Aggressively manage cardiovascular risk factors including hypertension and dyslipidemia 1, 2
• Target blood pressure <130/80 mmHg 1
• For established atherosclerotic cardiovascular disease, use SGLT2 inhibitors or GLP-1 receptor agonists with proven cardiovascular benefit 1

Diabetic Kidney Disease

• Screen regularly for albuminuria and reduced eGFR 3
• Use SGLT2 inhibitors in patients with CKD to reduce progression of kidney disease 1
• Optimize blood pressure control with ACE inhibitors or ARBs in patients with albuminuria 2

Retinopathy

• Conduct regular eye examinations for early detection and treatment 3
• Maintain optimal glycemic and blood pressure control to prevent or slow progression 3

Neuropathy and Diabetic Foot

• Screen for neuropathy and foot complications routinely 3
• Provide appropriate foot care education and referral to podiatry when needed 3
• For patients with diabetic neuropathy, consider appropriate pain management 2

Special Considerations

• For frail elderly patients or those with limited life expectancy, consider less stringent glycemic targets (A1C <8.0%) to avoid hypoglycemia 1
• In patients with type 2 diabetes and obesity, prioritize weight management with high-potency GLP-1 receptor agonists or dual GIP/GLP-1 receptor agonists that can achieve >5-10% weight loss 2
• Monitor for vitamin B12 deficiency in patients on long-term metformin therapy 1

Common Pitfalls to Avoid

• Delaying intensification of therapy when glycemic targets are not met 1
• Failing to address all cardiovascular risk factors comprehensively 1, 4
• Not considering medication costs and access issues that may affect adherence 1
• Overlooking the importance of regular screening for complications 3
• Neglecting to adjust therapy based on changes in renal function, particularly with SGLT2 inhibitors which have reduced glycemic benefits at eGFR <45 mL/min/1.73 m² 1, 5