What should be included in the first-line treatment for glycemic control in diabetes?

First-Line Treatment for Glycemic Control in Diabetes According to AACE

According to the American Diabetes Association (ADA) guidelines, lifestyle modifications should be included in the first-line treatment for glycemic control in diabetes. 1

Recommended First-Line Approach

• Lifestyle modifications are the foundation of any diabetes treatment program, including physical activity, weight loss education, and dietary interventions 1
• For newly diagnosed patients who are overweight or obese, lifestyle modifications should begin immediately, including physical activity and counseling to lose at least 5% of body weight 1
• Adults with Type 2 diabetes should perform at least 150 minutes per week of moderate-intensity physical activity or 75 minutes of vigorous-intensity physical activity to improve glycemic control 1
• A tailored nutrition plan focusing on a heart-healthy dietary pattern is recommended to improve glycemic control and achieve weight loss if needed 1

Pharmacological Treatment

• When lifestyle efforts alone have not achieved or maintained glycemic goals, metformin (a biguanide) should be added at, or soon after diagnosis, unless contraindicated or not tolerated 1
• Metformin is the preferred initial pharmacologic agent for type 2 diabetes because it is:
  • Effective and safe 1
  • Inexpensive and widely available 1
  • Associated with reduced risks of microvascular complications, cardiovascular events, and death 1
  • Weight neutral and does not cause hypoglycemia when used as monotherapy 1

Treatment Intensification

• If lifestyle efforts and metformin are not sufficient to maintain or achieve glycemic goals, additional agents may be considered 1
• For patients with A1C ≥9%, initial dual-regimen combination therapy should be considered to more quickly achieve glycemic control 1
• When blood glucose levels are very high (≥300-350 mg/dL) or A1C is ≥10-12%, especially if symptomatic, insulin therapy should be strongly considered from the outset 1

Special Considerations

• For patients with established atherosclerotic cardiovascular disease or indicators of high cardiovascular risk, a GLP-1 receptor agonist is preferred to insulin when possible 1
• Patient-centered factors should guide the choice of pharmacologic agents, including efficacy, cost, potential side effects, effects on weight, comorbidities, risk for hypoglycemia, and patient preferences 1

Common Pitfalls to Avoid

• Delaying treatment intensification when glycemic targets are not met 1
• Failing to address lifestyle modifications as the foundation of diabetes management 1
• Overlooking the importance of patient education and self-management training 1
• Not considering vitamin B12 deficiency with long-term metformin use, which may require periodic testing 1

In conclusion, while metformin is the preferred first-line pharmacological agent for type 2 diabetes, lifestyle modifications remain the foundation of any diabetes treatment program and should be initiated first or concurrently with medication.