What is the initial management approach for type 2 diabetes?

Initial Management Approach for Type 2 Diabetes

The initial management of type 2 diabetes should begin with metformin therapy concurrent with lifestyle modifications including nutrition and physical activity, unless specific circumstances require insulin as first-line treatment. 1

First-Line Pharmacologic Therapy

• Metformin is the recommended first-line pharmacologic treatment for type 2 diabetes when not contraindicated 2, 1
• Start metformin 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, 3
• For patients with metabolically stable diabetes (A1C <8.5% and asymptomatic), metformin monotherapy is appropriate if renal function is normal 2
• 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 4

Special Circumstances Requiring Insulin First

Insulin therapy should be initiated instead of metformin as first-line treatment in the following situations:

• Patients with marked hyperglycemia (blood glucose ≥250 mg/dL, A1C ≥8.5%) who are symptomatic with polyuria, polydipsia, nocturia, and/or weight loss 2, 1
• Patients with ketosis or diabetic ketoacidosis 2, 1
• Patients with severe hyperglycemia (blood glucose ≥600 mg/dL) who should be assessed for hyperglycemic hyperosmolar nonketotic syndrome 2
• When the distinction between type 1 and type 2 diabetes is unclear 2

Concurrent Lifestyle Modifications

• Initiate lifestyle management and diabetes education at diagnosis, alongside pharmacologic therapy 2, 1
• Physical activity recommendations should include at least 150 minutes per week of moderate-intensity activity 4, 5
• Weight management with an initial goal of 5-7% of baseline weight for overweight or obese patients 4, 5
• A multidisciplinary approach including a physician, diabetes educator, registered dietitian, and psychologist or social worker is beneficial 2

Treatment Intensification Algorithm

If glycemic targets are not met with metformin monotherapy:

1. Consider adding an SGLT-2 inhibitor or GLP-1 receptor agonist, particularly for patients with:

   • Cardiovascular disease (SGLT-2 inhibitors reduce risk for all-cause mortality, MACE, CKD progression, and CHF hospitalization) 2
   • Chronic kidney disease (prioritize SGLT-2 inhibitors) 2
   • Increased stroke risk or when weight loss is an important goal (prioritize GLP-1 agonists) 2

2. Avoid adding DPP-4 inhibitors to metformin, as they do not reduce morbidity or all-cause mortality 2

3. For youth with type 2 diabetes (age ≥10 years) not meeting targets on metformin, consider GLP-1 receptor agonist therapy if no history of medullary thyroid carcinoma or multiple endocrine neoplasia type 2 2

Monitoring and Follow-up

• Monitor HbA1c every 3 months until target is reached, then at least twice yearly 1
• Aim for HbA1c levels between 7% and 8% in most adults with type 2 diabetes 2
• Consider deintensifying pharmacologic treatments in adults with HbA1c levels less than 6.5% 2
• Self-monitoring of blood glucose might be unnecessary in patients receiving metformin combined with either an SGLT-2 inhibitor or a GLP-1 agonist 2

Common Pitfalls to Avoid

• Delaying treatment intensification when glycemic targets are not met (clinical inertia) 1
• When adding an SGLT-2 inhibitor or GLP-1 agonist that results in adequate glycemic control, failing to reduce or discontinue existing treatment with sulfonylureas or long-acting insulins, which increases risk for severe hypoglycemia 2
• Not monitoring for adverse events related to fluid retention when initiating or increasing doses of certain medications 6
• Not adjusting medications during periods of acute illness or procedures 1
• Not addressing comorbidities such as obesity, dyslipidemia, hypertension, and microvascular complications 2