What is the step-by-step management plan for type 2 diabetes (T2D) in India?

Diabetic Management Plan Step by Step in India

The most effective management plan for Type 2 Diabetes (T2DM) in India should begin with lifestyle modifications including diet and physical activity, followed by metformin as first-line pharmacological therapy, with subsequent stepwise addition of other medications based on glycemic control and comorbidities.

Initial Assessment and Diagnosis

• Complete a thorough evaluation to classify diabetes, detect complications, review previous treatment, and formulate a management plan 1 • Essential investigations should include HbA1c, fasting and postprandial blood glucose, lipid profile, kidney function tests, liver function tests, and urine microalbumin 2 • Screen for autoimmune conditions in Type 1 diabetes patients 1 • Assess for comorbidities such as hypertension, dyslipidemia, obesity, and cardiovascular disease 3

Step 1: Lifestyle Modifications

Physical Activity

• Recommend 150 minutes or more of moderate-to-vigorous intensity aerobic activity per week, spread over at least 3 days with no more than 2 consecutive days without activity 1, 4 • Include 2-3 sessions of resistance exercise per week on non-consecutive days 1 • Break up prolonged sitting every 30 minutes for blood glucose benefits 1, 4 • For children and adolescents, recommend 60 minutes/day of moderate or vigorous-intensity aerobic activity 1

Dietary Management

• Refer to a registered dietitian for individualized Medical Nutrition Therapy (MNT) 1 • Focus on portion control and healthy food choices for those with limited health literacy 1 • Emphasize carbohydrate intake from vegetables, fruits, legumes, whole grains, and dairy products with higher fiber and lower glycemic load 1 • Reduce intake of refined carbohydrates, added sugars, and sugar-containing beverages 1, 4 • Limit sodium consumption to <2,300 mg/day 1 • For those who consume alcohol, limit to one drink per day for women and two drinks per day for men 1

Weight Management

• Target weight loss of 5-7% of initial body weight for those who are overweight or obese 4 • Create a caloric deficit of 500-1,000 calories per day from maintenance needs 4

Step 2: Pharmacological Management

First-Line Therapy

• Start metformin as first-line therapy at the time of diagnosis along with lifestyle modifications 1 • Begin with a low dose (500 mg once or twice daily) and gradually increase to minimize gastrointestinal side effects 1 • Monitor vitamin B12 levels in patients taking metformin due to risk of deficiency 1, 4

Second-Line Therapy (If HbA1c target not achieved after 3 months)

• Add a second agent based on patient-specific factors:

• Sulfonylureas (like glipizide or gliclazide) if cost is a major concern 5
• DPP-4 inhibitors if hypoglycemia is a concern
• SGLT-2 inhibitors if patient has cardiovascular disease or chronic kidney disease
• GLP-1 receptor agonists if weight loss is desired 1
• Thiazolidinediones (like pioglitazone) if insulin resistance is predominant 6

Insulin Therapy

• Consider initiating insulin therapy if:

• Patient presents with random blood glucose ≥250 mg/dL 1
• HbA1c >9% 1
• Patient is ketotic or in diabetic ketoacidosis 1
• Oral agents fail to achieve glycemic targets 1

Step 3: Monitoring and Follow-up

• Monitor HbA1c every 3 months and intensify treatment if targets are not met 1 • Recommend finger-stick blood glucose monitoring for patients:

• Taking insulin or medications with risk of hypoglycemia 1
• Initiating or changing diabetes treatment regimen 1
• Not meeting treatment goals 1
• Having intercurrent illnesses 1 • Consider continuous glucose monitoring (CGM) for patients requiring frequent blood glucose monitoring 1

Step 4: Complication Screening and Management

• Screen regularly for microvascular complications:

• Annual comprehensive eye examination 7
• Annual urine microalbumin test 7
• Annual foot examination 7 • Assess and manage cardiovascular risk factors:
• Blood pressure (target <140/90 mmHg)
• Lipid profile (target LDL <100 mg/dL)
• Aspirin therapy for those at increased cardiovascular risk 3 • Screen for diabetes-related comorbidities including sleep apnea, cognitive decline, and bone metabolism impairments 7

Step 5: Patient Education and Support

• Provide diabetes self-management education and support (DSMES) 1 • Educate about hypoglycemia recognition and management 2 • Consider telemedicine support for real-time, frequent communication with healthcare providers 8 • Address barriers to self-monitoring and medication adherence, including financial constraints, complex medication regimens, and social stigma 9

Special Considerations for Indian Context

• Recognize that T2DM in India often presents at a younger age compared to Western populations 1 • Consider more stringent glycemic targets (HbA1c <6.5%) for younger patients without comorbidities 1 • Address financial barriers to comprehensive care, as many patients may choose to spend money only on medications rather than monitoring supplies 9 • Educate communities about health insurance options to address the financial burden of diabetes management 9 • Combat social stigma around insulin use through community education 9

Common Pitfalls to Avoid

• Delaying initiation of medication therapy while relying solely on lifestyle modifications 1 • Failing to screen for complications at the time of diagnosis 2 • Not educating patients about hypoglycemia recognition and management 2 • Neglecting to consider cultural factors and family dynamics in treatment planning 9 • Overlooking vitamin B12 deficiency in patients on long-term metformin therapy 1