What is the stepwise management of diabetes?

Stepwise Management of Diabetes

Foundation: All Patients Start Here

All patients with diabetes must begin with comprehensive lifestyle modifications including diabetes self-management education, medical nutrition therapy by a registered dietitian, and at least 150 minutes of moderate-intensity aerobic activity weekly with resistance training twice per week. 1

• Diabetes self-management education and support (DSMES) is associated with improved A1C, reduced mortality risk, and lower healthcare costs 1
• Medical nutrition therapy can reduce A1C by 1.0-1.9% in type 1 diabetes and 0.3-2% in type 2 diabetes 1
• Weight loss of at least 5% is recommended for overweight/obese patients with type 2 diabetes 1

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Type 1 Diabetes Management

Patients with type 1 diabetes require multiple-dose insulin injections (≥3 injections daily) or continuous subcutaneous insulin infusion from diagnosis. 1

Insulin Regimen Specifics:

• Use insulin analogues rather than regular insulin to reduce hypoglycemia risk 1
• Educate patients on matching prandial insulin doses to carbohydrate intake, preprandial glucose levels, and anticipated activity 1
• Consider continuous glucose monitoring systems to significantly reduce severe hypoglycemia risk 1
• Insulin pump therapy with low glucose "suspend" feature reduces nocturnal hypoglycemia without increasing A1C 1

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Type 2 Diabetes Management: Stepwise Algorithm

Step 1: Initial Therapy at Diagnosis

Start metformin at or soon after diagnosis (if tolerated and not contraindicated) along with lifestyle modifications. 1, 2

• Metformin is the preferred initial pharmacologic agent based on efficacy, safety, low cost, and potential cardiovascular benefits 1, 2
• Metformin can be continued with declining renal function down to GFR 30-45 mL/min with dose reduction 1
• Exception: If patient has established atherosclerotic cardiovascular disease, heart failure, chronic kidney disease, or high cardiovascular risk, consider starting a GLP-1 receptor agonist or SGLT2 inhibitor at diagnosis alongside metformin 1, 2

Step 2: Dual Therapy (If A1C Target Not Met After 3 Months)

Add a second agent when monotherapy at maximum tolerated dose fails to achieve or maintain A1C target over 3 months. 1

Choice of second agent depends on specific patient factors:

If patient has established ASCVD, heart failure, or CKD:

• Add GLP-1 receptor agonist (preferred) or SGLT2 inhibitor 1, 2
• These agents reduce cardiovascular events by 12-26%, heart failure by 18-25%, and kidney disease progression by 24-39% over 2-5 years 2

If patient does not have cardiovascular/renal comorbidities, choose based on:

• Sulfonylureas: Low cost, but cause hypoglycemia and weight gain 1
• DPP-4 inhibitors: Weight neutral, low hypoglycemia risk 1
• SGLT2 inhibitors: Cause weight loss, low hypoglycemia risk, GU infections possible 1
• GLP-1 receptor agonists: Significant weight loss (>5-10%), low hypoglycemia risk, GI side effects 1, 2
• Thiazolidinediones: Weight gain, fluid retention, heart failure risk 1
• Basal insulin: Most effective for glucose lowering, causes hypoglycemia and weight gain 1

Special circumstance: If A1C ≥9% at diagnosis, start dual therapy immediately to achieve glycemic control more rapidly 1

Step 3: Triple Therapy or Insulin Initiation

If dual therapy fails to maintain A1C target, add a third oral agent or initiate basal insulin. 1

• If using insulin, combination therapy with a GLP-1 receptor agonist is recommended 1
• Among patients with established ASCVD or high cardiovascular risk, GLP-1 receptor agonist is preferred over insulin when possible 1

Step 4: Intensification with Insulin

When blood glucose levels are 300-350 mg/dL or greater and/or A1C is 10-12%, especially if symptomatic or catabolic features present, initiate basal insulin plus mealtime insulin 1

• Start with basal insulin (NPH, glargine, detemir, or degludec) 1
• Add prandial insulin if basal insulin alone insufficient 1
• Avoid overbasalization: Clinical signals include basal dose >0.5 units/kg/day, high bedtime-morning glucose differential, hypoglycemia, or high glycemic variability 1

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Critical Safety Considerations

Hypoglycemia Prevention:

• Severe or frequent hypoglycemia is an absolute indication for treatment regimen modification 1
• Do not aggressively pursue near-normal A1C in patients with advanced disease, hypoglycemia unawareness, or those at high risk 1
• Patients with hypoglycemia unawareness should increase glycemic targets for several weeks 1

Monitoring Requirements:

• Reassess medication regimen every 3-6 months and adjust based on A1C, side effects, and patient factors 1
• Increase blood glucose monitoring frequency during any insulin regimen changes 1, 3

Treatment Intensification Timeline:

• Do not delay treatment intensification when glycemic targets are not met 1
• Reevaluate within 3 months if monotherapy inadequate 1