What is the recommended follow-up and management plan for patients with type 2 diabetes?

Type 2 Diabetes Follow-Up and Management Plan

Patients with type 2 diabetes should be reassessed every 3-6 months with medication adjustments as needed, prioritizing SGLT2 inhibitors or GLP-1 receptor agonists in those with cardiovascular/kidney disease, and metformin for others, while monitoring HbA1c targets, weight goals, and screening for complications. 1

Medication Review and Adjustment Schedule

Reevaluate the medication plan every 3-6 months and adjust based on glycemic control, weight goals, and comorbidities 1. Do not delay treatment intensification if goals are not met 1.

First-Line Therapy Selection

• For patients WITHOUT cardiovascular or kidney disease: Start or continue metformin (unless contraindicated) addressing both glycemic and weight goals 1
• For patients WITH heart failure (reduced or preserved ejection fraction): Use SGLT2 inhibitor for glycemic management and prevention of heart failure hospitalizations 1
• For patients WITH chronic kidney disease (eGFR 20-60 mL/min/1.73 m² and/or albuminuria): Use SGLT2 inhibitor to minimize CKD progression, reduce cardiovascular events, and reduce heart failure hospitalizations 1
• For patients WITH advanced CKD (eGFR <30 mL/min/1.73 m²): Prefer GLP-1 receptor agonist for lower hypoglycemia risk and cardiovascular event reduction 1

Add-On Therapy Algorithm

If glycemic targets are not achieved on first-line therapy 1:

• Second agent: Add GLP-1 RA (including dual GIP/GLP-1 RA) which is preferred over insulin for greater weight loss and lower hypoglycemia risk 1
• For persistent albuminuria >30 mg/g with normal potassium in type 2 diabetes: Add nonsteroidal mineralocorticoid receptor antagonist 1
• If insulin becomes necessary: Combine with GLP-1 RA for greater glycemic effectiveness, beneficial weight effects, and reduced hypoglycemia risk; reassess insulin dosing upon GLP-1 RA addition 1

Insulin Initiation Criteria

Start insulin immediately if 1:

• Evidence of ongoing catabolism (unexpected weight loss)
• Symptoms of hyperglycemia present
• HbA1c >10% (>86 mmol/mol) OR
• Blood glucose ≥300 mg/dL (≥16.7 mmol/L)

Glycemic Monitoring and Targets

• HbA1c testing: Every 3 months to evaluate treatment response, as it reflects glycemia over the past 2-3 months 1, 2
• Target HbA1c: Generally <7% for intensive control, which reduces microvascular disease by 3.5%, myocardial infarction by 3.3-6.2%, and mortality by 2.7-4.9% over long-term follow-up 3
• Self-monitoring frequency: At mealtimes for those on insulin secretagogues or insulin; individualize based on medication regimen 1

Hypoglycemia Prevention and Management

Risk Reduction Strategies

For patients on insulin secretagogues 1:

• Consume moderate carbohydrate amounts at each meal and snacks
• Never skip meals
• Always carry a carbohydrate source during physical activity

For patients on insulin 1:

• If on multiple daily injections or pump: take mealtime insulin before eating; lower dose if physical activity within 1-2 hours
• If on premixed insulin: take doses at consistent times daily; eat meals at similar times; never skip meals
• If on fixed insulin: eat similar carbohydrate amounts daily to match insulin doses

Hypoglycemia Treatment

When blood glucose is <70 mg/dL 1:

• Treat with 15-20 g of glucose (glucose tablets, fruit juice, sports drinks, regular soda, or hard candy)
• Recheck blood glucose after 15-20 minutes
• Repeat treatment if hypoglycemia persists
• For patients on α-glucosidase inhibitors: Use monosaccharides (glucose tablets) only, as the drug prevents polysaccharide digestion 1

Complication Screening Schedule

Retinopathy Screening

• Initial examination: Within 3-5 years of type 1 diabetes diagnosis; shortly after type 2 diabetes diagnosis 1
• Follow-up frequency: Annually by ophthalmologist or optometrist experienced in diabetic retinopathy 1
• More frequent examinations: Required if retinopathy is progressing 1
• Immediate referral: For any level of macular edema, severe nonproliferative diabetic retinopathy, or any proliferative diabetic retinopathy 1

Kidney Disease Monitoring

• Regular assessment: eGFR and albuminuria every 3-6 months 1
• Medication adjustments: Metformin can be continued when eGFR ≥30 mL/min/1.73 m²; SGLT2 inhibitors should be initiated when eGFR ≥20 mL/min/1.73 m² and continued until dialysis or transplantation 1

Cardiovascular Risk Assessment

• Lipid management: Statin therapy recommended for all patients with type 2 diabetes and CKD 1
• Blood pressure control: RAS blockade (ACE inhibitor or ARB) for patients with albuminuria and hypertension 1
• Antiplatelet therapy: For those with established atherosclerotic cardiovascular disease 1

Nutrition and Lifestyle Management

Dietary Recommendations

• Sodium restriction: Limit to 2,300 mg/day 1
• Alcohol consumption: Only with food to reduce hypoglycemia risk for those on insulin or insulin secretagogues 1
• Carbohydrate management: For insulin users, learn carbohydrate counting to match mealtime insulin to carbohydrate intake 1
• No single optimal diet: Mediterranean-style, DASH-style, plant-based, lower-fat, and lower-carbohydrate patterns all show effectiveness 1

Weight Management

• Target: Weight loss of 2-8 kg provides clinical benefits, especially early in disease 1
• Interventions: Intensive lifestyle programs with frequent follow-up required for significant weight reduction 1
• Medication support: High-potency GLP-1 RA and dual GIP/GLP-1 RA result in >5% weight loss in most individuals, potentially exceeding 10% 3

Physical Activity

• Benefits: Reduces HbA1c by 0.4-1.0% and improves cardiovascular risk factors 3
• Hypoglycemia precaution: Always carry carbohydrate source during exercise, especially for those on insulin or insulin secretagogues 1

Medication-Specific Monitoring

Metformin

• Initiation: Start at low dose with gradual titration to minimize gastrointestinal side effects 1
• Administration: Take with food or 15 minutes after meals if symptoms persist 1
• Vitamin B12 monitoring: Periodic testing recommended due to association with deficiency and neuropathy symptoms 1

GLP-1 Receptor Agonists

• Titration: Gradual dose escalation to minimize gastrointestinal side effects 1
• Timing: Daily or twice-daily formulations should be premeal; once-weekly formulations can be taken anytime regardless of meals 1
• Follow-up: If side effects persist beyond a few weeks, contact provider 1

SGLT2 Inhibitors

• Monitoring: Watch for signs of volume depletion and genital mycotic infections 1
• Continuation: Maintain therapy as tolerated until dialysis or transplantation, even as eGFR declines (glycemic benefits reduced at eGFR <45 mL/min/1.73 m²) 1

Special Populations

Older Adults with Advanced Disease

For stable patients 1:

• Continue previous regimen focusing on hypoglycemia prevention
• Keep glucose levels below renal threshold
• Minimal role for HbA1c monitoring and aggressive lowering

For patients with organ failure 1:

• Hypoglycemia prevention is paramount
• Reduce insulin secretagogue doses as oral intake decreases
• Allow glucose values in upper level of target range

Pregnancy Planning

• Preconception: Comprehensive eye examination and counseling on retinopathy risk 1
• During pregnancy: First trimester comprehensive eye examination with close follow-up throughout pregnancy 1

Common Pitfalls to Avoid

• Overbasalization with insulin: Evaluate if basal dose >0.5 IU/kg/day, high bedtime-morning glucose differential, hypoglycemia, or high glycemic variability occur; reevaluate and individualize therapy 1
• Sliding scale insulin monotherapy: Avoid prolonged use; implement scheduled basal-bolus regimens instead 1
• Delaying treatment intensification: Do not wait if glycemic goals are not met; adjust therapy promptly 1
• Continuing all medications during insulin initiation: Glucose-lowering agents may be continued unless contraindicated or not tolerated 1