Clinical Guidelines for Type 2 Diabetes Mellitus Management
The American College of Physicians strongly recommends adding an SGLT-2 inhibitor or a GLP-1 agonist to metformin and lifestyle modifications in adults with type 2 diabetes and inadequate glycemic control to reduce mortality and morbidity. 1
First-Line Management
- Metformin (unless contraindicated) combined with lifestyle modifications remains the cornerstone of initial type 2 diabetes management for most patients 1, 2
- Target HbA1c levels should be between 7% and 8% for most adults, with deintensification of pharmacologic treatments when HbA1c is less than 6.5% 1
- Lifestyle modifications should include:
- At least 150 minutes per week of moderate-intensity physical activity or 75 minutes of vigorous-intensity activity for adults 3, 2
- Dietary patterns focusing on Mediterranean, DASH, or plant-based diets with emphasis on fiber-rich whole grains and reduced refined carbohydrates 3, 4
- Weight management with an initial goal of 7-10% weight loss for patients with overweight or obesity 2, 5
Medication Selection Algorithm
When to Add Second-Line Therapy
- Add second-line therapy when glycemic targets are not met with metformin and lifestyle modifications 1
- For patients with inadequate glycemic control, choose between:
Specific Benefits of Second-Line Medications
SGLT-2 inhibitors reduce:
- All-cause mortality
- Major adverse cardiovascular events (MACE)
- Progression of chronic kidney disease
- Hospitalization due to congestive heart failure 1
GLP-1 receptor agonists reduce:
- All-cause mortality
- Major adverse cardiovascular events
- Stroke 1
DPP-4 inhibitors are NOT recommended as add-on therapy to metformin due to lack of mortality benefit 1
Special Clinical Considerations
- Self-monitoring of blood glucose might be unnecessary in patients receiving metformin combined with either an SGLT-2 inhibitor or a GLP-1 agonist 1
- When adding an SGLT-2 inhibitor or GLP-1 agonist results in adequate glycemic control, reduce or discontinue existing treatment with sulfonylureas or long-acting insulins to avoid hypoglycemia 1
- Sulfonylureas and long-acting insulins are inferior to SGLT-2 inhibitors and GLP-1 agonists in reducing mortality and morbidity but may still have limited value for glycemic control 1
- Consider cost implications when selecting medications, as there are currently no generic SGLT-2 inhibitors or GLP-1 agonists available 1
Monitoring and Follow-Up
- Assess glycemic status at least every 3 months using HbA1c, which better reflects long-term control than fasting plasma glucose 2, 6
- Evaluate response to therapy after 3 months of treatment to determine if medication adjustments are needed 6
- Regularly assess for cardiovascular risk factors and complications, as approximately one-third of adults with type 2 diabetes have cardiovascular disease 4
Collaborative Care Approach
- Implement collaborative care plans that integrate:
- Dietary improvement and weight management
- Physical activity
- Sleep health
- Stress management
- Management of comorbidities and concomitant medications 1
- Involve clinical pharmacists to reduce polypharmacy risks 1
- Assess and address social risk factors that may impact diabetes management 1
Common Pitfalls to Avoid
- Delaying treatment intensification when glycemic targets are not met 2
- Failing to adjust medications during acute illness 2
- Not recognizing differences between type 1 and type 2 diabetes, especially in younger patients with obesity 2
- Overlooking the need to reduce or discontinue sulfonylureas or insulin when adding SGLT-2 inhibitors or GLP-1 agonists, which can lead to hypoglycemia 1
- Focusing solely on glycemic control without addressing cardiovascular and renal risk reduction 4