What is the management of type 2 diabetes mellitus (DM)?

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. 1, 2, 3

Initial Treatment Algorithm

Patients Requiring Immediate Insulin Therapy

Start insulin immediately (0.5 units/kg/day) if ANY of the following are present: 4, 2, 3

• Ketosis or diabetic ketoacidosis 4, 2
• Random blood glucose ≥250 mg/dL 4, 2
• HbA1c ≥8.5% 4, 2
• Unclear distinction between Type 1 and Type 2 diabetes 4, 3

After metabolic stabilization, add metformin to the insulin regimen. 3 Many patients can eventually be weaned from insulin and managed with metformin plus lifestyle modifications. 4

Metabolically Stable Patients

• Start metformin 500 mg daily at diagnosis 2, 3
• Titrate by 500 mg every 1-2 weeks to target dose of 2000 mg daily in divided doses 1, 4, 2
• Begin comprehensive lifestyle modifications simultaneously—this is not optional 4

Comprehensive Lifestyle Modifications

Nutrition Management

Refer to a registered dietitian nutritionist with diabetes expertise at diagnosis. 4, 2

• Implement Mediterranean, DASH, or vegetarian/vegan dietary patterns 1, 2, 3
• Focus on fiber-rich whole grains and avoid refined carbohydrates 1, 4
• Reduce red meat consumption 1, 2
• Completely eliminate sugar-added beverages 4
• Ensure nutrition plans are culturally appropriate and sensitive to family resources 4, 2
• No single dietary pattern works for everyone; develop a personal food plan based on individual preferences and context 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

Children/Adolescents: Minimum 60 minutes daily of moderate-to-vigorous exercise 4, 3

• Combine aerobic and resistance training for optimal glycemic control 1, 2
• Break up sedentary time with 5-minute activity breaks every hour 1
• Use the "talk test" to gauge intensity: during moderate activity, you can talk but not sing; during vigorous activity, you cannot talk without pausing 4
• Include muscle-strengthening and bone-strengthening activities at least 3 days per week 4

Screen Time Management (Pediatric Patients)

• Limit non-academic screen time to <2 hours daily 4, 3
• Remove video screens and televisions from children's bedrooms 4

Weight Management Strategy

Target at least 5% weight loss for clinical benefits; substantial weight loss (>10%) early in disease course increases chance of remission. 1, 2

• For most patients, aim for 7-10% decrease in excess weight 4, 3
• Consider GLP-1 receptor agonists with high weight loss efficacy, which can provide 10-15% weight loss or more 1, 2
• Metabolic surgery should be considered for patients without sufficient response to non-surgical interventions, particularly early in disease course, and performed in high-volume centers with experienced multidisciplinary teams 1, 2

Monitoring Protocol

HbA1c Monitoring

• Check HbA1c every 3 months until target achieved 1, 4, 2, 3
• Target HbA1c <7% for most patients 4, 2
• In the absence of hypoglycemia, even lower HbA1c targets can be considered 4

Finger-Stick Blood Glucose Monitoring

Indicated for patients who are: 4, 2, 3

• Taking insulin or medications with hypoglycemia risk 4, 2
• Initiating or changing diabetes treatment regimen 4, 2
• Not meeting treatment goals 4, 2
• Experiencing intercurrent illnesses 4, 2

Treatment Intensification Strategy

If glycemic targets are 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

• Approved for pediatric use and effective for decreasing HbA1c and promoting weight loss 4
• Provide 10-15% weight loss or more 1, 2
• Contraindicated in patients with family history of medullary thyroid cancer 4, 2
• Increase gastrointestinal side effects 4

SGLT-2 Inhibitors

• Empagliflozin is now approved for pediatric Type 2 diabetes 4
• Consider for patients with additional ASCVD risk factors 1, 2

Diabetes Self-Management Education

All patients and their families should receive comprehensive diabetes self-management education (DSMES) that is culturally appropriate, starting immediately at diagnosis. 4, 2

• Provide education at diagnosis, annually, with changes in health status, and with transitions of care 2
• Establish SMART goals (Specific, Measurable, Attainable, Relevant, Time-based) for behavior change rather than non-specific recommendations 1, 2
• Avoid an "all or none" approach—any improvement in healthy behaviors can have positive impact 1
• Self-monitoring of achievements (physical activity monitoring, weight measurement) is crucial 1

Family-Centered Approach (Pediatric Patients)

Both the youth and parents/caregivers are responsible for diabetes management, requiring a team effort with comprehensive diabetes education for the entire family. 4

• The entire family must adopt healthy eating habits and lifestyle changes 4, 3
• Engage the family to maintain lifestyle changes and foster medication adherence 1
• Ensure culturally appropriate, family-centered care along with ongoing education 1

Essential Multidisciplinary Team Members

• Physician 4
• Certified Diabetes Care and Education Specialist (CDCES) 4
• Registered dietitian nutritionist 4
• Behavioral health specialist or social worker 4

Critical Pitfalls to Avoid

• Do not delay metformin initiation—early aggressive treatment provides better long-term outcomes 3
• Do not overlook cardiovascular risk stratification; consider moderate-intensity statin therapy for patients aged 40-75 years 3
• Recognize that adding medications or insulin when metformin alone doesn't achieve goals is not a failure but reflects disease progression 4
• Understand the patient and family's perception of the disease before establishing a management plan to dispel misconceptions and promote adherence 1