What are the recommended treatments for managing diabetes?

Recommended Treatments for Managing Diabetes

Metformin is the first-line pharmacologic therapy for type 2 diabetes, alongside comprehensive lifestyle modifications including nutrition therapy and physical activity. 1, 2

Initial Management Approach

Lifestyle Modifications

• All patients with diabetes should receive comprehensive diabetes self-management education focusing on healthy eating patterns and physical activity 2
• Structured programs emphasizing lifestyle changes including education, reduced fat (<30% of daily energy) and energy intake, regular physical activity, and regular participant contact can produce long-term weight loss of 5-7% of starting weight 3
• Physical activity recommendations include at least 150 minutes of moderate-intensity aerobic activity per week, reduced sedentary time, and resistance training at least twice per week 3, 2
• Nutrition therapy should focus on healthy eating patterns emphasizing nutrient-dense, high-quality foods and decreased consumption of calorie-dense, nutrient-poor foods 2

Pharmacologic Therapy for Type 2 Diabetes

• Metformin should be initiated at or soon after diagnosis if not contraindicated, starting 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, 2
• Metformin works by lowering blood sugar through reducing glucose production in the liver and improving insulin sensitivity 4
• Common side effects of metformin include gastrointestinal symptoms (which are often transient) and a metallic taste that typically resolves quickly 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
  • Random blood glucose ≥250 mg/dL
  • HbA1c >9% (>75 mmol/mol)
  • Severe hyperglycemia with catabolism
  • Symptomatic diabetes with polyuria, polydipsia, and weight loss 1, 2

Treatment Intensification Algorithm

When Initial Therapy Is Insufficient

• When monotherapy with metformin at the maximum tolerated dose does not achieve or maintain the HbA1c target over 3 months, a second agent should be added 3
• Second-line options to combine with metformin include:
  • SGLT-2 inhibitors (especially for patients with cardiovascular or kidney disease)
  • GLP-1 receptor agonists
  • Sulfonylureas
  • Thiazolidinediones
  • DPP-4 inhibitors
  • Basal insulin 3, 2
• Selection should be based on patient factors, disease characteristics, drug properties, and patient preferences 3

Insulin Therapy

• For type 1 diabetes, multiple-dose insulin injections (≥3 injections per day) or continuous subcutaneous insulin infusion are recommended 3
• For type 2 diabetes, insulin therapy should be considered when triple therapy fails to achieve glycemic targets 1
• Start with basal insulin (typically 0.5 units/kg/day) and titrate every 2-3 days based on blood glucose monitoring 1
• Insulin options include:
  • Basal insulins (glargine, detemir, degludec) 5, 6
  • Rapid-acting insulins for mealtime coverage when needed 3
• Patients should be educated on matching prandial insulin doses to carbohydrate intake, preprandial blood glucose levels, and anticipated activity level 3

Glycemic Targets and Monitoring

• A reasonable HbA1c goal for most adults with diabetes is <7% 2
• More stringent targets (such as <6.5%) may be appropriate for selected individuals if achievable without significant hypoglycemia 2
• HbA1c should be monitored every 3 months until target is reached, then at least twice yearly 1
• Self-monitoring of blood glucose or continuous glucose monitoring should be used to guide therapy adjustments 1

Hypoglycemia Management

• Hypoglycemia may be reversed with administration of 15-20g of rapid-acting glucose 3
• Initial response to treatment should be seen in 10-20 minutes; however, blood glucose should be evaluated in 60 minutes, as additional treatment may be necessary 3
• Patients should be educated on situations that increase their risk for hypoglycemia, such as fasting for tests or procedures, during or after exercise, and during sleep 3
• Patients using insulin should always carry a source of quick-acting carbohydrates to reduce risk of hypoglycemia 3

Common Pitfalls to Avoid

• Delaying treatment intensification when glycemic targets are not met (clinical inertia) 1, 2
• Not adjusting medications during periods of acute illness or procedures 1
• Failing to recognize the difference between type 1 and type 2 diabetes, especially in children and adolescents with obesity 2
• Overlooking the importance of lifestyle modifications as a fundamental component of diabetes management 7
• Not considering medication side effects, particularly hypoglycemia risk with insulin and sulfonylureas 5, 6

Special Considerations

For Elderly Patients

• Energy requirements for older adults are less than for younger adults 3
• Physical activity should be encouraged, but caution should be exercised when prescribing weight-loss diets as undernutrition is more likely than overnutrition in the elderly 3

For Patients with Comorbidities

• For individuals with elevated LDL cholesterol, saturated fatty acids and trans-saturated fatty acids should be limited to <10% and perhaps to <7% of energy 3
• For patients with hypertension, sodium intake should be reduced to 2,400 mg (100 mmol) or sodium chloride to 6,000 mg per day 3
• For individuals with microalbuminuria, reduction of protein to 0.8–1.0 g/kg body weight per day, and in individuals with overt nephropathy, reduction to 0.8 g/kg body weight per day, may slow the progression of nephropathy 3