What are the recommended treatment regimens for type 1 and type 2 diabetes?

Recommended Treatment Regimens for Type 1 and Type 2 Diabetes

For type 1 diabetes, multiple daily injections (MDI) of insulin or continuous subcutaneous insulin infusion (CSII) is the cornerstone of treatment, while type 2 diabetes treatment should begin with metformin and progress to combination therapy or insulin based on glycemic control and cardiorenal risk factors. 1

Type 1 Diabetes Treatment

Insulin Regimens

• Most people with type 1 diabetes should be treated with multiple daily injections (three to four injections per day of basal and prandial insulin) or continuous subcutaneous insulin infusion (CSII/insulin pump) 1
• Rapid-acting insulin analogs should be used to reduce hypoglycemia risk compared to regular human insulin 1
• Typical starting insulin dose is based on weight, with doses ranging from 0.4 to 1.0 units/kg/day, with higher amounts required during puberty 1
• Generally, patients require about 50% of their daily insulin as basal and 50% as prandial insulin 1

Insulin Types and Administration

• Basal insulin: Long-acting insulin analogs (glargine, detemir, degludec) are preferred over NPH insulin due to lower risk of hypoglycemia 1, 2
• Prandial insulin: Rapid-acting analogs (aspart, lispro, glulisine) should be administered 0-15 minutes before meals 3, 4
• Patients should match prandial insulin doses to carbohydrate intake, premeal blood glucose levels, and anticipated physical activity 1

Monitoring and Technology

• Continuous glucose monitoring (CGM) improves outcomes with both injected and infused insulin 1
• Automated insulin delivery (AID) systems may be considered for patients capable of using the device safely to improve time in range and reduce hypoglycemia 1
• For patients with frequent nocturnal hypoglycemia or hypoglycemia unawareness, sensor-augmented low glucose threshold suspend pumps should be considered 1

Type 2 Diabetes Treatment

Initial Therapy

• Metformin is the preferred initial pharmacological agent for type 2 diabetes if not contraindicated and if tolerated 1
• Lifestyle modifications including weight loss, dietary changes, and increased physical activity should be implemented concurrently 1

Combination Therapy

• When monotherapy with metformin at maximum tolerated dose does not achieve or maintain HbA1c target over 3 months, a second agent should be added 1
• In adults with type 2 diabetes and established/high risk of atherosclerotic cardiovascular disease, heart failure, and/or chronic kidney disease, the treatment regimen should include agents that reduce cardiorenal risk 1
• For patients with weight management goals, treatment regimens should consider approaches that support weight management 1

Insulin Initiation in Type 2 Diabetes

• Insulin therapy should be considered when HbA1c is ≥7.5% despite optimal use of other agents, and is essential when HbA1c is ≥10% 5
• The preferred method of insulin initiation is to begin with a long-acting (basal) insulin or once-daily premixed/co-formulation insulin, alone or in combination with GLP-1 receptor agonists or oral antidiabetic drugs 1, 5
• In adults with type 2 diabetes, a GLP-1 receptor agonist is preferred to insulin when possible 1
• If insulin is used, combination therapy with a GLP-1 receptor agonist is recommended for greater efficacy, durability, and weight and hypoglycemia benefits 1

Insulin Intensification

• If basal insulin alone is insufficient, rapid-acting or short-acting insulin can be added at mealtime to control postprandial glucose excursions 5
• Early introduction of insulin should be considered if there is evidence of ongoing catabolism (weight loss), symptoms of hyperglycemia, or when A1C levels (>10%) or blood glucose levels (≥300 mg/dL) are very high 1
• Metformin should be continued upon initiation of insulin therapy for ongoing glycemic and metabolic benefits 1

Common Pitfalls and Considerations

Hypoglycemia Management

• Glucose (15-20g) is the preferred treatment for conscious persons with hypoglycemia (glucose value ≤70 mg/dL) 1
• Patients should be educated on hypoglycemia recognition and management, especially those on intensive insulin regimens 1
• Insulin analogs are associated with less hypoglycemia compared to human insulins while providing similar glycemic control 1, 2, 3

Insulin Administration Technique

• The shortest needles (4-mm pen and 6-mm syringe needles) are safe, effective, and less painful 5
• Intramuscular injections should be avoided, especially with long-acting insulins, as severe hypoglycemia may result 5
• Injection sites should be rotated to prevent lipohypertrophy, which can distort insulin absorption 5

Special Considerations

• Patients who have been successfully using CSII should have continued access to this therapy after they turn 65 years of age 1
• Medication regimen should be reevaluated at regular intervals (every 3-6 months) and adjusted as needed 1
• Treatment intensification for individuals not meeting treatment goals should not be delayed 1

By following these evidence-based treatment regimens and considering individual patient factors, optimal glycemic control can be achieved while minimizing the risk of complications in both type 1 and type 2 diabetes.