Optimal Management of a Known Diabetic Patient
All diabetic patients should receive diabetes self-management education, individualized medical nutrition therapy (preferably by a registered dietitian), and a structured physical activity plan consisting of at least 150 minutes of moderate-intensity aerobic activity per week plus resistance training at least twice weekly, alongside metformin as first-line pharmacologic therapy unless contraindicated. 1
Foundational Management Components
Lifestyle Interventions (Non-Negotiable Foundation)
- Diabetes self-management education and support is mandatory for all patients with diabetes to prevent acute complications and reduce long-term risks 1
- Medical nutrition therapy should be provided by a registered dietitian for all persons with diabetes, with goals including at least 5% body weight loss in overweight/obese patients 1
- Physical activity prescription must include:
Glucose Monitoring Strategy
- Self-monitoring of blood glucose (SMBG) frequency depends on treatment regimen 1:
- Patients on multiple daily insulin injections or pump therapy: before meals/snacks, occasionally postprandially, at bedtime, before exercise, when suspecting hypoglycemia, after treating hypoglycemia, and before critical tasks like driving 1
- Patients on less intensive regimens: as part of broader educational context to guide treatment decisions 1
- Hemoglobin A1c testing should be performed at least every 3 months to assess glycemic control 1
Pharmacologic Management Algorithm
Type 2 Diabetes (Most Common Scenario)
Initial Therapy
- Metformin is the preferred first-line agent and should be initiated at or soon after diagnosis if lifestyle modifications are insufficient 1
- Metformin offers cardiovascular benefits, may reduce risk for cardiovascular events and death, is inexpensive, and has long-established safety 1
- Start at low dose with gradual titration due to gastrointestinal side effects 1
- Can be continued with declining renal function down to GFR 30-45 mL/min with dose reduction 1
When to Escalate Beyond Metformin
Add a second agent when monotherapy at maximum tolerated dose fails to achieve or maintain HbA1c target over 3 months 1
For patients with established cardiovascular disease, kidney disease, or high cardiovascular risk: Add GLP-1 receptor agonist or SGLT2 inhibitor early, as these reduce atherosclerotic cardiovascular disease risk by 12-26%, heart failure risk by 18-25%, and kidney disease progression by 24-39% over 2-5 years 2
For patients with HbA1c ≥9.0% at baseline: Consider starting combination therapy with two non-insulin agents or insulin directly, as monotherapy has low probability of achieving near-normal targets 1
For patients with HbA1c ≥10% or glucose >300-350 mg/dL with hyperglycemic symptoms: Insulin therapy should be strongly considered from the outset 1
Combination Therapy Options
After metformin, consider adding one of these six agents based on patient-specific factors (efficacy, cost, side effects including weight and hypoglycemia risk, comorbidities, patient preferences) 1:
- Sulfonylureas
- GLP-1 receptor agonists (preferred if cardiovascular/kidney disease present) 2
- SGLT2 inhibitors (preferred if cardiovascular/kidney disease present) 2
- DPP-4 inhibitors 2
- Thiazolidinediones 2
- Basal insulin 1
Metformin should be continued when adding insulin as this combination reduces weight gain, lowers insulin dose requirements, and decreases hypoglycemia compared to insulin alone 3
Type 1 Diabetes
- Multiple-dose insulin injections (≥3 injections daily) or continuous subcutaneous insulin infusion are required for most patients, as this reduces microvascular complications and cardiovascular disease risk 1
- Insulin analogues should be used rather than regular insulin to reduce hypoglycemia risk 1
- Patients require education on matching prandial insulin to carbohydrate intake, preprandial glucose levels, and anticipated activity 1
- Continuous glucose monitoring significantly reduces severe hypoglycemia risk and should be offered 1
Hypoglycemia Prevention and Management
Recognition and Treatment
- Hypoglycemia is defined as plasma glucose <70 mg/dL and is the major limiting factor in glycemic management of insulin-treated diabetes 1
- Treat with 15-20 grams of rapid-acting glucose (pure glucose preferred); confirm reversal with SMBG after 15 minutes and repeat if needed 1
- Prescribe glucagon to all patients at risk for severe hypoglycemia and train close contacts on administration 1
High-Risk Situations
Educate patients on increased hypoglycemia risk during 1:
- Fasting for tests or procedures
- During or after exercise
- During sleep
- After alcohol consumption 4
Hypoglycemia Unawareness
- Increase glycemic targets for at least several weeks to partially reverse hypoglycemia unawareness and reduce future episode risk 1
- Severe or frequent hypoglycemia is an absolute indication for treatment regimen modification 1
Critical Pitfalls to Avoid
- Do not aggressively pursue near-normal HbA1c in patients with advanced disease or those unable to safely achieve targets, as this increases hypoglycemia risk without benefit 1
- Never use sliding-scale insulin alone in hospitalized patients; use basal-bolus regimens instead 1
- Do not abruptly discontinue oral medications when starting insulin due to rebound hyperglycemia risk 3
- Avoid intramuscular insulin injections, especially with long-acting formulations, as severe hypoglycemia may result 3
- Do not inject into lipohypertrophic areas as this distorts insulin absorption; rotate injection sites properly 3
Comprehensive Cardiovascular Risk Management
Screening and treatment of modifiable cardiovascular risk factors is essential, as approximately one-third of adults with type 2 diabetes have cardiovascular disease 1, 2. Address hypertension, dyslipidemia, and smoking cessation alongside glycemic control 1.