Recommended Treatment Options for Diabetes Management
The cornerstone of diabetes management includes comprehensive lifestyle modifications as the foundation, with metformin as first-line pharmacologic therapy for type 2 diabetes, followed by a stepwise approach to medication intensification based on individual patient factors and treatment goals. 1, 2
Initial Management: Lifestyle Modifications
- All patients with diabetes should receive comprehensive diabetes self-management education focusing on healthy eating patterns and physical activity 1
- 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 1
- Nutrition therapy should emphasize nutrient-dense, high-quality foods while decreasing calorie-dense, nutrient-poor foods 1
- For overweight or obese adults with type 2 diabetes, reducing energy intake while maintaining a healthful eating pattern is recommended to promote weight loss 1
- Modest weight loss (5-7% of starting weight) can provide clinical benefits including improved glycemia, blood pressure, and lipids 1
Pharmacologic Management for Type 2 Diabetes
First-Line Therapy
- Metformin is recommended as the first-line medication for type 2 diabetes when not contraindicated, starting at a low dose and increasing gradually to an ideal maximum dose of 2000 mg daily in divided doses 1, 2
- Metformin is preferred due to its efficacy, safety, low cost, and potential cardiovascular benefits 1
- Common side effects include metallic taste (in about 3% of patients) and rarely causes hypoglycemia by itself 3
Special Circumstances Requiring Insulin First
- Insulin therapy should be initiated instead of metformin as first-line treatment in patients with:
Treatment Intensification
When metformin at maximum tolerated dose does not achieve or maintain the HbA1c target over 3 months, add a second agent from the following options:
Pioglitazone, when added to existing therapy, can reduce HbA1c by 0.7-1.3% when combined with sulfonylurea, 0.8-1.0% when combined with metformin, and 0.7-1.0% when combined with insulin 4
Management for Type 1 Diabetes
- Most patients with type 1 diabetes should be treated with multiple-dose insulin injections (≥3 injections per day) or continuous subcutaneous insulin infusion 1
- Insulin analogs should be used to reduce hypoglycemia risk 1
- Patients should be educated on matching prandial insulin doses to carbohydrate intake, preprandial blood glucose levels, and anticipated activity level 1
- Continuous glucose monitoring systems can significantly reduce severe hypoglycemia risk 1
Glycemic Targets and Monitoring
- A reasonable HbA1c goal for most adults with diabetes is <7%, with more stringent targets (such as <6.5%) for selected individuals 1, 2
- HbA1c should be monitored every 3 months until target is reached, then at least twice yearly 1, 2
- Treatment goals should be individualized based on patient factors including age, comorbidities, and risk of hypoglycemia 1
Hypoglycemia Management
- Hypoglycemia (plasma glucose level <3.9 mmol/L) can be reversed with 15-20g of rapid-acting glucose 1, 2
- Blood glucose should be confirmed after 15 minutes, and the process repeated if hypoglycemia persists 1
- Patients should be educated about situations that increase hypoglycemia risk, such as fasting, exercise, and sleep 1, 2
- Severe or frequent hypoglycemia requires modification of treatment regimens 1
Special Populations
Children and Adolescents with Type 2 Diabetes
- Initial management should include lifestyle modifications and diabetes education, with metformin recommended as initial therapy for A1C <8.5% without acidosis or ketosis 1
- For A1C ≥8.5% or with ketosis, insulin therapy should be initiated until acidosis resolves 1
Hypertension Management in Diabetes
- Treatment of elevated blood pressure should focus on lifestyle modification including healthy nutrition, physical activity, sleep, and weight management 1
- ACE inhibitors or angiotensin receptor blockers should be started for confirmed hypertension 1
Common Pitfalls and Caveats
- Patients with hypoglycemia unawareness should increase their glycemic targets temporarily to partially reverse this condition and reduce future risk 1
- Avoid aggressively targeting near-normal HbA1c levels in patients with advanced disease where such targets cannot be safely reached 1
- Metformin rarely causes hypoglycemia by itself, but hypoglycemia can occur if patients do not eat enough, drink alcohol, or take other medicines to lower blood sugar 3
- For many patients, a comprehensive approach addressing all six pillars of lifestyle medicine (plant-predominant nutrition, regular physical activity, restorative sleep, stress reduction, social connectedness, and avoiding risky substances) may be most effective 5