Type 2 Diabetes Mellitus Management Guidelines Flowchart
The management of Type 2 Diabetes Mellitus (T2DM) should follow a structured approach focusing on medication therapy alongside comprehensive lifestyle modifications to reduce morbidity and mortality.
Initial Assessment and Treatment Decision
- For children and adolescents with T2DM who are ketotic, in diabetic ketoacidosis, or when distinction between T1DM and T2DM is unclear: Initiate insulin therapy immediately 1
- For children and adolescents with random blood glucose ≥250 mg/dL or HbA1c >9%: Start insulin therapy 1
- For all other newly diagnosed T2DM patients: Start metformin as first-line therapy alongside lifestyle modifications 1
Medication Management
Initial Diagnosis of T2DM
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Is patient ketotic/in DKA OR BG ≥250 mg/dL OR HbA1c >9%?
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YES NO
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Start insulin Start metformin + lifestyle modifications
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Monitor HbA1c every 3 months
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Treatment goals met?
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YES NO
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Continue Intensify treatment:
therapy • Adjust current medication
• Consider adding SGLT-2 inhibitor or GLP-1 agonist
• Consider insulin if needed- Metformin dosing: Start at 500 mg daily, increase by 500 mg every 1-2 weeks to ideal dose of 2000 mg daily in divided doses 1
- For patients with additional ASCVD risk factors: Consider adding SGLT-2 inhibitor or GLP-1 receptor agonist if glucose control inadequate with metformin 1
- Pioglitazone: May be used as adjunct to diet and exercise, starting at 15-30 mg once daily, maximum 45 mg daily 2
Monitoring Protocol
- HbA1c monitoring: Check every 3 months 1
- Finger-stick blood glucose monitoring: Recommended for patients who 1:
- Are taking insulin or medications with hypoglycemia risk
- Are initiating or changing treatment regimen
- Have not met treatment goals
- Have intercurrent illnesses
Lifestyle Modifications
Nutrition
- Implement evidence-based nutrition guidelines focusing on weight management 1
- Recommended dietary patterns: Mediterranean, DASH, or vegetarian/vegan diets 1
- Carbohydrate quality: Focus on fiber-rich whole grains, avoid refined carbohydrates 1, 3
- Reduce red meat consumption to improve glycemic control 1
Physical Activity
- Adults with T2DM: At least 150 minutes per week of moderate-intensity or 75 minutes of vigorous-intensity physical activity 1
- Children and adolescents with T2DM: At least 60 minutes daily of moderate-to-vigorous exercise 1
- Exercise prescription: Provide written prescription with specific duration, intensity, and frequency 1
- Activity definition: Use "talk test" - during moderate activity, a person can talk but not sing; during vigorous activity, cannot talk without pausing 1
- Combine aerobic and resistance training for optimal glycemic control 1
Screen Time Management
- Limit non-academic screen time to less than 2 hours per day 1
- Discourage video screens and TVs in children's bedrooms 1
Common Barriers to Address
- Dietary adherence barriers: Cost and access to food, lack of knowledge about appropriate portions, separate food preparation challenges, conflicting dietary information 4
- Physical activity barriers: Comorbidities, fear of public ridicule, lack of structured exercise programs 5, 4
- Behavioral change challenges: Different stages of readiness for diet versus physical activity changes, with many patients showing resistance to physical activity changes 6