What is the recommended approach to manage type 2 diabetes?

Management of Type 2 Diabetes

The most effective approach to manage type 2 diabetes involves a comprehensive strategy combining lifestyle modifications, medication therapy, and diabetes self-management education, with metformin as first-line therapy and addition of SGLT2 inhibitors or GLP-1 receptor agonists for those with cardiovascular or kidney disease. 1

Lifestyle Interventions

Physical Activity

• Patients should perform at least 150 minutes per week of moderate-intensity aerobic physical activity (50-70% of maximum heart rate), spread over at least 3 days with no more than 2 consecutive days without exercise 1
• Resistance training should be performed at least twice weekly to improve insulin sensitivity and glycemic control 1
• Breaking up sedentary time with activity breaks (e.g., 5-minute activity break every hour) provides additional benefits 1
• For those with complications such as peripheral neuropathy, non-weight-bearing activities may be necessary 2

Nutrition

• No single dietary pattern is recommended for all individuals with type 2 diabetes; dietary plans should be individualized based on preferences and context 1
• Focus on consuming a diet high in vegetables, fruits, whole grains, fiber, legumes, plant-based proteins, unsaturated fats, and nuts; and lower in processed meats, refined carbohydrates, and sweetened beverages 1, 3
• Limit sodium intake to less than 2g per day (or <5g sodium chloride) 1
• For those with diabetes and chronic kidney disease not on dialysis, maintain protein intake at 0.8g/kg body weight/day 1

Weight Management

• For patients with overweight or obesity, target at least 5% weight loss, which provides clinical benefits for glycemic control 1, 4
• Substantial weight loss (>10%) early in the course of type 2 diabetes increases the chance of disease remission 1
• Consider GLP-1 receptor agonists with high weight loss efficacy for patients needing significant weight reduction (10-15% or more) 1

Pharmacological Management

First-Line Therapy

• Metformin is the preferred first-line medication for most patients with newly diagnosed type 2 diabetes if kidney function is normal (eGFR ≥30 ml/min per 1.73 m²) 1
• Start metformin at a low dose and gradually titrate to minimize gastrointestinal side effects 1, 5

Additional Therapy

• For patients with type 2 diabetes and chronic kidney disease with eGFR ≥30 ml/min per 1.73 m², add a sodium-glucose cotransporter-2 inhibitor (SGLT2i) 1
• For patients not achieving glycemic targets with metformin and SGLT2i, or unable to use these medications, add a long-acting glucagon-like peptide-1 receptor agonist (GLP-1 RA) 1, 4
• For patients with high baseline HbA1c (≥9.0%), consider starting with a combination of two non-insulin agents or with insulin 1
• For patients with significant hyperglycemic symptoms or dramatically elevated glucose levels (>300-350 mg/dL) or HbA1c (≥10.0-12.0%), insulin therapy should be strongly considered initially 1

Glycemic Monitoring and Targets

• Use hemoglobin A1c (HbA1c) to monitor glycemic control 1
• Individualize HbA1c targets ranging from <6.5% to <8.0% based on patient factors 1
• For most patients, a reasonable HbA1c target is <7.0% 3
• More stringent targets (<6.5%) may be appropriate for selected individuals if achievable without significant hypoglycemia 3
• Assess glycemic status at least every 3 months 3

Diabetes Self-Management Education and Support (DSMES)

• DSMES is as important to the management plan as medication selection and should be offered at diagnosis, annually, with changes in health status, and during transitions of care 1
• Implement a structured self-management educational program for all patients with diabetes 1
• DSMES should be provided by trained diabetes care and education specialists 1

Special Considerations

Cardiovascular Risk Reduction

• Comprehensive cardiovascular risk reduction must be a major focus of therapy 1
• For patients with established cardiovascular disease or at high cardiovascular risk, prioritize SGLT2i and/or GLP-1 RA medications that have demonstrated cardiovascular benefits 4

Chronic Kidney Disease

• For patients with diabetes and chronic kidney disease, treatment with an ACE inhibitor or ARB should be initiated if hypertension and albuminuria are present 1
• SGLT2i have shown significant benefits for kidney disease progression (24-39% risk reduction) 4

Common Pitfalls and Caveats

• Avoid "quick-fix" weight loss programs that are rarely effective long-term and do not promote healthy eating behaviors 1
• When prescribing metformin, be aware of potential side effects including gastrointestinal issues and metallic taste, which typically resolve over time 5
• For patients on insulin or insulin secretagogues, ensure they understand the risk of hypoglycemia with exercise and the importance of not skipping meals 1
• Regular physical activity must be maintained consistently as benefits deteriorate within 72 hours of the last exercise session 2
• For patients with diabetic complications (retinopathy, neuropathy), modify exercise recommendations appropriately to prevent injury 1