What are the management options for Type 2 Diabetes Mellitus (T2DM)?

Management of Type 2 Diabetes Mellitus

Start metformin 500 mg daily alongside comprehensive lifestyle modifications immediately at diagnosis for all newly diagnosed T2DM patients, unless they present with ketosis, diabetic ketoacidosis, random blood glucose ≥250 mg/dL, or HbA1c ≥8.5%—in which case, initiate insulin therapy first at 0.5 units/kg/day. 1, 2, 3

Initial Assessment and Treatment Algorithm

Immediate Insulin Therapy Required If ANY of the Following:

• Ketosis or diabetic ketoacidosis present 1, 2, 3
• Random blood glucose ≥250 mg/dL 1, 2, 3
• HbA1c ≥8.5% (≥69 mmol/mol) 1, 3
• Unclear distinction between Type 1 and Type 2 diabetes 1, 3

For these high-risk patients, start insulin at 0.5 units/kg/day, then add metformin after metabolic stabilization 3. Many patients can subsequently be weaned from insulin and managed with metformin and lifestyle modifications 1, 3.

Standard First-Line Therapy (All Other Patients):

• Start metformin 500 mg daily, increase by 500 mg every 1-2 weeks to target dose of 2000 mg daily in divided doses 1, 2, 4
• Metformin decreases hepatic glucose output and sensitizes peripheral tissues to insulin 5
• Begin comprehensive lifestyle modifications simultaneously—this is not optional 1, 2

Comprehensive Lifestyle Modifications

Nutrition Management

• Implement Mediterranean, DASH, or vegetarian/vegan dietary patterns focusing on fiber-rich whole grains and reduced red meat consumption 1, 2, 3
• Completely eliminate sugar-added beverages 1, 2, 3
• Refer to registered dietitian nutritionist with diabetes expertise at diagnosis 1, 2
• Ensure nutrition plans are culturally appropriate and sensitive to family resources 1
• Adopt a family-centered approach with the entire family adopting healthy eating habits 1

Physical Activity Requirements

• Adults: Minimum 150 minutes per week of moderate-intensity OR 75 minutes per week of vigorous-intensity physical activity 1, 2, 3, 5
• Combine aerobic and resistance training for optimal glycemic control 1, 2
• Children/adolescents: Minimum 60 minutes daily of moderate-to-vigorous exercise, including muscle and bone strengthening activities at least 3 days per week 1, 3
• Use "talk test" to define activity level: during moderate activity, can talk but not sing; during vigorous activity, cannot talk without pausing 1

Weight Management

• Target 7-10% weight loss from baseline body weight for those with overweight or obesity 1, 3
• At least 5% weight loss provides clinical benefits, with substantial weight loss (>10%) early in disease course increasing chance of remission 2

Screen Time Management (Pediatric Patients)

• Limit non-academic screen time to less than 2 hours per day 1
• Remove video screens and televisions from children's bedrooms 1

Monitoring Protocol

HbA1c Monitoring

• Check HbA1c every 3 months until target achieved 1, 2, 3
• Target HbA1c <7% for most patients 1, 2, 3
• In absence of hypoglycemia, even lower HbA1c targets can be considered 6
• Intensify treatment if goals not met at 3-month intervals 1, 2

Blood Glucose Monitoring

Finger-stick blood glucose monitoring is indicated for patients who are: 1, 2

• Taking insulin or medications with hypoglycemia risk
• Initiating or changing diabetes treatment regimen
• Not meeting treatment goals
• Experiencing intercurrent illnesses

Treatment Intensification Strategy

When to Add Second Agent (After 3 Months on Metformin)

If glycemic targets not achieved after 3 months on metformin, add SGLT-2 inhibitor or GLP-1 receptor agonist for patients with additional ASCVD risk factors or established cardiovascular/kidney disease. 1, 2, 3

GLP-1 Receptor Agonists

• Effective for decreasing HbA1c and promoting weight loss (10-15% or more) 2, 3
• Particularly effective for patients with obesity 2
• Contraindicated in patients with family history of medullary thyroid cancer 1, 3
• May increase gastrointestinal side effects 1, 3
• Now approved for pediatric use 1

SGLT-2 Inhibitors

• Empagliflozin now approved for pediatric Type 2 diabetes 1, 3
• Demonstrated cardiovascular and kidney benefits 3

Insulin Therapy in Combination

• Can be initiated at 15-30 mg once daily when added to existing regimen 7
• Decrease insulin dose by 10-25% if patient reports hypoglycemia or plasma glucose <100 mg/dL 7

Cardiovascular Risk Management

• Consider moderate-intensity statin therapy for patients aged 40-75 years 3
• Address comorbidities at diagnosis: obesity management, dyslipidemia, hypertension, and microvascular complications screening 1, 3

Metabolic Surgery Consideration

• Consider metabolic surgery for patients without sufficient response to non-surgical weight loss interventions, particularly early in disease course 2, 3
• Should be performed in high-volume centers with experienced multidisciplinary teams 2

Diabetes Self-Management Education

• Provide comprehensive diabetes self-management education (DSMES) at diagnosis, annually, with changes in health status, and with transitions of care 2
• Education must be culturally appropriate and specific to the patient's diabetes type 1
• Establish SMART goals (Specific, Measurable, Attainable, Relevant, Time-based) for behavior change 2

Common Pitfalls to Avoid

• Do not delay insulin therapy in patients meeting high-risk criteria—immediate insulin therapy may actually increase long-term adherence by enhancing perception of disease seriousness 1
• Do not treat lifestyle modifications as optional—they must begin simultaneously with pharmacotherapy 1, 2
• Do not wait longer than 3 months to intensify therapy if glycemic targets are not met 1, 2
• Metformin rarely causes hypoglycemia by itself, but risk increases if patient does not eat enough, drinks alcohol, or takes other glucose-lowering medications 4
• Maximum metformin dose should not exceed 2000 mg daily in divided doses 1