What are the initial management recommendations for diabetes mellitus type 2?

Initial Management of Type 2 Diabetes Mellitus

The initial management of type 2 diabetes mellitus should include lifestyle modifications and metformin as first-line pharmacologic therapy, unless specific circumstances require insulin initiation. 1

Lifestyle Modifications

• All patients with type 2 diabetes should receive comprehensive diabetes self-management education that is culturally appropriate and focuses on healthy eating patterns and physical activity 2
• Patients with overweight or obesity should be provided with developmentally appropriate lifestyle programs aimed at achieving at least a 7-10% decrease in excess weight 2
• Physical activity recommendations include at least 60 minutes of moderate to vigorous physical activity daily with muscle and bone strengthening exercises at least 3 days per week 2
• Nutrition should focus on healthy eating patterns emphasizing nutrient-dense, high-quality foods and decreased consumption of calorie-dense, nutrient-poor foods, particularly sugar-added beverages 2
• Long-term high adherence to a Mediterranean diet is associated with a reduced risk of developing type 2 diabetes 3

Pharmacologic Therapy

First-Line Therapy: Metformin

• Metformin should be initiated at or soon after diagnosis if not contraindicated 1
• Start at a low dose of 500 mg daily, increasing by 500 mg every 1-2 weeks, up to an ideal maximum dose of 2000 mg daily in divided doses 1, 4
• Metformin decreases hepatic glucose output and sensitizes peripheral tissues to insulin, and has been shown to decrease mortality rates in patients with type 2 diabetes 5
• Common side effects include gastrointestinal symptoms (abdominal discomfort, bloating, loose stools) which are often transient 2, 4

Special Circumstances Requiring Insulin First

Insulin therapy should be initiated instead of metformin as first-line treatment in patients with:

• Ketosis or diabetic ketoacidosis 2, 1
• Random blood glucose ≥250 mg/dL 2, 1
• HbA1c >8.5% (>69 mmol/mol) 2
• Symptomatic hyperglycemia with polyuria, polydipsia, nocturia, and/or weight loss 2, 1

Glycemic Targets and Monitoring

• A reasonable HbA1c goal for most adults with type 2 diabetes is <7% 2
• More stringent targets (such as <6.5%) may be appropriate for selected individuals if achievable without significant hypoglycemia 2
• Glycemic status should be assessed at least every 3 months 2
• Self-monitoring of blood glucose might be unnecessary in patients receiving metformin alone 2

Treatment Intensification

If glycemic targets are not met with metformin and lifestyle modifications:

• Consider adding an SGLT-2 inhibitor or GLP-1 receptor agonist, particularly in patients with cardiovascular or kidney disease 2, 6
• SGLT-2 inhibitors reduce the risk for all-cause mortality, major adverse cardiovascular events, progression of chronic kidney disease, and hospitalization due to heart failure 2
• GLP-1 receptor agonists reduce the risk for all-cause mortality, major adverse cardiovascular events, and stroke 2
• The American College of Physicians recommends against adding a DPP-4 inhibitor to metformin 2

Common Pitfalls to Avoid

• Delaying treatment intensification when glycemic targets are not met (clinical inertia) 1
• Failing to adjust medications during periods of acute illness or procedures 1
• Not recognizing the difference between type 1 and type 2 diabetes, especially in children and adolescents with obesity 2
• Overlooking cardiovascular risk factor management, which should be addressed concurrently with glycemic control 6, 5
• Neglecting to monitor for complications of diabetes such as diabetic kidney disease, retinopathy, and neuropathy 7

Special Considerations for Children and Adolescents

• For children and adolescents with type 2 diabetes, the approach is similar but requires age-appropriate considerations 2
• In youth with newly diagnosed type 2 diabetes with poor glycemic control (BG ≥250 mg/dL or HbA1c >9%) but without ketosis, short-term insulin therapy may be beneficial 2
• Many pediatric patients with type 2 diabetes can be weaned gradually from insulin therapy and subsequently managed with metformin and lifestyle modification 2