What are the steps in treating diabetes?

Treatment Steps for Diabetes

Diabetes treatment follows a structured, stepwise approach beginning with immediate diagnosis and classification, followed by lifestyle interventions and pharmacologic therapy tailored to comorbidities, with regular monitoring and intensification as needed to prevent complications and optimize quality of life. 1

Step 1: Initial Evaluation and Classification

At diagnosis, perform comprehensive assessment to classify diabetes type and establish baseline:

• Measure HbA1c, fasting glucose, lipid profile, kidney function (creatinine, eGFR), and urine albumin-to-creatinine ratio 1
• Screen for autoimmune conditions in type 1 diabetes (thyroid peroxidase antibodies, thyroglobulin antibodies, tissue transglutaminase for celiac disease) 2, 1
• Assess for existing complications: retinopathy (comprehensive eye exam), nephropathy (albuminuria), neuropathy (foot examination), and cardiovascular disease 1
• Evaluate comorbidities including obesity, hypertension, dyslipidemia, and heart failure 1

Step 2: Establish Individualized Glycemic Targets

Set HbA1c goals based on patient-specific factors:

Patient Category	HbA1c Target	Rationale
Most adults with type 2 diabetes	<7%	Standard target for preventing microvascular complications [2]
Elderly with multiple comorbidities or limited life expectancy	8-8.5%	Reduces hypoglycemia risk and mortality [3]
Patients with severe hypoglycemia history	8-8.5%	Hypoglycemia carries 1.81-3.21 fold increased mortality risk [3]
Newly diagnosed, long life expectancy, no cardiovascular disease	<6.5%	More aggressive control when safe [2]
Patients with advanced complications or frailty	Relax targets	Prioritize quality of life over tight control [2]

Step 3: Implement Lifestyle Modifications (Concurrent with Pharmacotherapy)

Initiate medical nutrition therapy and physical activity immediately:

• Nutrition: Individualized meal planning with no single ideal macronutrient distribution; consider Mediterranean, DASH, plant-based, or lower-carbohydrate patterns based on patient preference 1
• Physical activity: 30-60 minutes of moderate aerobic activity daily, at least 5 days per week, plus resistance training twice weekly 2, 1
• Weight management: For overweight/obese patients, prescribe 500-750 kcal/day energy deficit targeting ≥5% weight loss through high-intensity behavioral therapy 1
• Diabetes self-management education (DSMES): Provide at diagnosis covering hypoglycemia/hyperglycemia recognition, medication administration, glucose monitoring, and nutritional management 1

Step 4: Initiate Pharmacologic Therapy

Type 2 Diabetes - First-Line Treatment

Start pharmacotherapy at diagnosis alongside lifestyle modifications:

Clinical Scenario	First-Line Agent	Rationale
No cardiovascular/kidney disease, metabolically stable	Metformin + lifestyle modification	Most effective, safe, inexpensive; may reduce cardiovascular events [2,1,4]
Heart failure (reduced or preserved ejection fraction)	SGLT2 inhibitor	Prevents HF hospitalizations and provides glycemic management [2]
CKD (eGFR 20-60 mL/min/1.73m² or albuminuria)	SGLT2 inhibitor	Minimizes CKD progression, reduces cardiovascular events and HF hospitalizations [2]
Advanced CKD (eGFR <30 mL/min/1.73m²)	GLP-1 RA	Lower hypoglycemia risk, cardiovascular event reduction [2]
Severe hyperglycemia (A1C >10% or glucose ≥300 mg/dL) or catabolic symptoms	Insulin (consider early)	Addresses severe metabolic derangement immediately [2]

Early combination therapy can be considered at treatment initiation to shorten time to glycemic goals 2

Type 1 Diabetes

Insulin is mandatory from diagnosis:

• Initiate basal-bolus insulin regimen or continuous subcutaneous insulin infusion 1
• Never discontinue basal insulin in type 1 diabetes, even with poor oral intake, as this precipitates diabetic ketoacidosis 3

Step 5: Intensify Therapy if Glycemic Targets Not Met

Reevaluate medication regimen every 3-6 months and adjust without delay if targets not achieved:

Type 2 Diabetes Intensification Algorithm

Current Therapy	Next Step	Key Considerations
Metformin monotherapy not at goal	Add agent based on comorbidities (see Step 4 table)	Prioritize SGLT2i if HF/CKD, GLP-1 RA if ASCVD risk [2]
Metformin + oral agent not at goal	Add GLP-1 RA (preferred over insulin)	Greater efficacy, weight benefit, lower hypoglycemia risk [2]
Multiple oral agents not at goal	Add GLP-1 RA or dual GIP/GLP-1 RA before insulin	Preferred to insulin for glycemic effectiveness and weight [2]
Requiring insulin	Combine insulin with GLP-1 RA or dual GIP/GLP-1 RA	Greater glycemic effectiveness, beneficial weight effects, reduced hypoglycemia; reassess insulin dosing upon GLP-1 RA addition [2]
Basal insulin at high doses (>0.5 IU/kg/day)	Evaluate for overbasalization; consider adding GLP-1 RA rather than increasing insulin	High bedtime-morning glucose differential, hypoglycemia, or high variability signals overbasalization [2]

Continue existing glucose-lowering agents when adding insulin unless contraindicated for ongoing metabolic benefits 2

Step 6: Manage Cardiovascular Risk Factors

Address all modifiable cardiovascular risk factors aggressively:

• Blood pressure: Target <140/90 mmHg (or <130/80 mmHg with CKD); initiate with beta blockers and/or ACE inhibitors as tolerated 2, 1
• Lipids: Manage aggressively, particularly in patients with cardiovascular disease; consider statins after age 10 if LDL ≥160 mg/dL or LDL ≥130 mg/dL with CVD risk factors, targeting LDL <100 mg/dL 2
• Antiplatelet therapy: Consider aspirin in appropriate patients with cardiovascular disease 1
• ACE inhibitors/ARBs: For microalbuminuria, titrate to normalize albumin excretion if possible 2

Step 7: Screen for and Prevent Complications

Implement regular screening protocols:

Complication	Screening Frequency	Intervention
Retinopathy	Annual comprehensive eye examination [1]	Refer to ophthalmology if abnormalities detected
Nephropathy	Annual urine albumin-to-creatinine ratio and eGFR [1]	Initiate ACE inhibitor/ARB for microalbuminuria [2]
Neuropathy	Annual comprehensive foot examination [1]	Foot care education, appropriate footwear
Cardiovascular disease	Regular assessment of risk factors [1]	Aggressive risk factor modification
Thyroid dysfunction (type 1)	TSH every 1-2 years after metabolic control established [2]	Treat hypothyroidism/hyperthyroidism as indicated
Celiac disease (type 1, if symptomatic)	Tissue transglutaminase or anti-endomysial antibodies with normal IgA [2]	Refer to gastroenterology; initiate gluten-free diet if confirmed

Provide all age-appropriate vaccinations 2, 1

Step 8: Special Populations - Elderly and End-of-Life Care

Elderly Patients with Hypoglycemia Risk

Modify treatment approach to prioritize safety:

• Target glucose range 140-180 mg/dL to balance control against hypoglycemia risk 3
• Relax A1C targets to 8-8.5% in patients with shortened life expectancy, significant comorbidities, or severe hypoglycemia history 3
• Avoid sliding-scale insulin alone (associated with poor outcomes and higher hypoglycemia rates) 3
• Consider basal insulin regimens alone rather than basal-bolus or premixed regimens to decrease hypoglycemia risk 3
• Assess for malnutrition risk factors: finances, meal preparation capacity, dentition problems, swallowing difficulties, cognitive impairment 3
• Avoid restrictive diets in patients >70 years or with undernutrition (increases sarcopenia risk) 3

End-of-Life/Palliative Care

Prioritize comfort and quality of life over glycemic targets:

Patient Category	Treatment Approach	Glucose Targets
Stable patient	Continue previous regimen with focus on preventing hypoglycemia and managing hyperglycemia below renal threshold [2]	Prevent hypoglycemia; allow upper target range
Organ failure	Prevent hypoglycemia and dehydration; reduce agents causing hypoglycemia; maintain small basal insulin in type 1 diabetes [2]	Upper level of desired range
Dying patient	Discontinue all medications in type 2 diabetes; small basal insulin only in type 1 diabetes [2]	Prevent acute hyperglycemic complications

Withdraw blood pressure and lipid therapy as appropriate; reduce frequency of glucose monitoring; avoid agents causing gastrointestinal symptoms or weight loss 2

Common Pitfalls to Avoid

• Do not delay treatment intensification when glycemic targets are not met 2
• Do not target tight glycemic control (A1C <7%) in elderly patients with multiple comorbidities (increases hypoglycemia risk without mortality benefit) 3
• Do not use premixed insulin formulations in elderly patients (threefold higher hypoglycemia rates) 3
• Do not stop basal insulin in type 1 diabetes even with poor oral intake (precipitates DKA) 3
• Do not use sliding-scale insulin as sole therapy in elderly patients (poor outcomes) 3
• Do not continue overbasalization of insulin (doses >0.5 IU/kg/day with persistent hyperglycemia signal need for regimen change, not more insulin) 2