What is the treatment for type 2 diabetes?

Treatment of Type 2 Diabetes

The first-line treatment for type 2 diabetes is metformin, which should be started at or soon after diagnosis, alongside comprehensive lifestyle modifications including nutrition therapy and physical activity. 1, 2

Initial Treatment Approach

Lifestyle Modifications

• All patients with type 2 diabetes should receive comprehensive diabetes self-management education focusing on healthy eating patterns and physical activity 2
• Physical activity recommendations include at least 150 minutes of moderate to vigorous physical activity per week with muscle strengthening exercises at least 3 days per week 1, 3
• Patients with overweight or obesity should aim for at least a 7-10% decrease in excess weight through appropriate lifestyle programs 2, 4
• Lifestyle modification should be continued throughout the course of diabetes treatment, not just as an initial step 5

First-Line Pharmacologic Therapy: Metformin

• Metformin is the preferred initial pharmacologic treatment for type 2 diabetes unless contraindicated 5, 1
• Start at a low dose (500 mg daily) and increase gradually by 500 mg every 1-2 weeks to minimize gastrointestinal side effects, up to an ideal maximum dose of 2000 mg daily in divided doses 2, 6
• Common side effects include gastrointestinal symptoms (bloating, abdominal discomfort, diarrhea) which are often transient 6
• Metformin has beneficial effects on A1C, weight, and cardiovascular mortality compared to sulfonylureas 5

Special Circumstances Requiring Insulin First

• Insulin therapy should be initiated instead of metformin as first-line treatment in patients with: 1, 2
  • Ketosis or diabetic ketoacidosis
  • Random blood glucose ≥250 mg/dL or HbA1c >8.5% with symptoms
  • Severe hyperglycemia with catabolism
  • Blood glucose ≥600 mg/dL

Glycemic Targets and Monitoring

• A reasonable HbA1c goal for most adults with type 2 diabetes is <7% 5, 2
• More stringent targets (such as <6.5%) may be appropriate for selected individuals with short duration of diabetes, long life expectancy, and no significant cardiovascular disease 5
• Less stringent targets (such as <8%) may be appropriate for patients with history of severe hypoglycemia, limited life expectancy, advanced complications, or extensive comorbidities 5
• Measure HbA1c at least every 3 months until target is reached, then at least twice yearly 5, 1

Treatment Intensification Algorithm

When metformin and lifestyle modifications fail to achieve glycemic targets:

1. For patients with established cardiovascular disease, heart failure, or chronic kidney disease:

   • Add an SGLT-2 inhibitor 5, 1

2. For patients with increased risk for stroke or for whom weight loss is an important goal:

   • Add a GLP-1 receptor agonist 5, 1, 4

3. For other patients:

   • Consider adding either a sulfonylurea, a thiazolidinedione, an SGLT-2 inhibitor, or a DPP-4 inhibitor to metformin 5
   • Selection should be based on discussing benefits, adverse effects, and costs with the patient 5

Common Pitfalls to Avoid

• Delaying treatment intensification when glycemic targets are not met (clinical inertia) 1, 2
• Failing to consider cardiovascular and renal benefits of newer agents (SGLT-2 inhibitors and GLP-1 receptor agonists) when selecting add-on therapy 1, 4
• Not adjusting medications during periods of acute illness 2
• Overlooking the importance of continued lifestyle modifications throughout treatment 5
• Not recognizing when insulin therapy is needed as initial treatment in cases of severe hyperglycemia 1, 2

Importance of Teamwork and Patient Empowerment

• Diabetes management requires a multidisciplinary team approach including nurses, dietitians, social workers, medical psychologists, and physicians 5
• Patient empowerment and involvement of family and friends is crucial for successful long-term management 5
• Communication and shared responsibilities between primary care providers and specialists is essential, with timely referral of difficult-to-manage cases 5

By following this treatment algorithm and addressing both pharmacologic therapy and lifestyle modifications, while avoiding common pitfalls, patients with type 2 diabetes can achieve better glycemic control and reduce the risk of complications.