What are the latest guidelines for managing type 1 and type 2 diabetes?

Latest Guidelines for Diabetes Management

Type 2 Diabetes Management

First-Line Therapy

Start all patients with metformin (unless contraindicated) plus lifestyle modifications, then add an SGLT-2 inhibitor or GLP-1 agonist when glycemic control remains inadequate. 1, 2, 3

• Metformin remains the mandatory first-line pharmacologic therapy for type 2 diabetes 2, 3
• Lifestyle modifications include 30 minutes of physical activity at least five times weekly, calorie restriction to 1500 kcal/day, and limiting fat to 30-35% of total energy intake 2
• Lifestyle interventions alone can decrease HbA1c by approximately 2% and produce 5 kg weight loss 2

Second-Line Therapy Selection Algorithm

When metformin plus lifestyle modifications fail to achieve glycemic targets, choose between SGLT-2 inhibitors and GLP-1 agonists based on the following hierarchy:

Prioritize SGLT-2 Inhibitors When:

• Patient has congestive heart failure 1, 2, 3
• Patient has chronic kidney disease 1, 2, 3, 4
• Primary goal is reducing cardiovascular mortality 2, 4
• Primary goal is reducing hospitalization for heart failure 3, 4
• Primary goal is preventing progression of kidney disease 4

Prioritize GLP-1 Agonists When:

• Patient has increased stroke risk 1, 2, 3
• Total body weight loss is an important treatment goal 1, 2, 4
• Patient needs all-cause mortality reduction without heart failure or CKD 2, 3

Glycemic Targets

Target HbA1c between 7% and 8% for most adults with type 2 diabetes. 1, 2, 3, 4

• Deintensify pharmacologic treatments when HbA1c falls below 6.5% to avoid hypoglycemia and overtreatment 1, 2, 3, 4
• Individualize targets based on hypoglycemia risk, life expectancy, diabetes duration, established vascular complications, and major comorbidities 1, 2, 4

Critical Safety Measures

When SGLT-2 inhibitors or GLP-1 agonists achieve adequate glycemic control, reduce or discontinue sulfonylureas or long-acting insulins immediately due to severe hypoglycemia risk. 1, 2, 3, 4

• Sulfonylureas and long-acting insulins are inferior to SGLT-2 inhibitors and GLP-1 agonists for reducing all-cause mortality and morbidity 1, 2, 3
• These older agents may still provide limited glycemic control value in cost-constrained situations 2, 3

What NOT to Use

Do not add DPP-4 inhibitors to metformin—they fail to reduce morbidity or all-cause mortality. 1, 3

This is a strong recommendation based on high-certainty evidence from the American College of Physicians 1

Monitoring Simplification

• Self-monitoring of blood glucose is unnecessary in patients receiving metformin combined with either an SGLT-2 inhibitor or GLP-1 agonist, as these combinations carry minimal hypoglycemia risk 1, 2, 3, 4
• Monitor for vitamin B12 deficiency with long-term metformin use, especially in patients with anemia or peripheral neuropathy 2

Comprehensive Risk Factor Management

Patients with diabetes and chronic kidney disease require a multi-pronged approach beyond glycemic control:

• RAS blockade (ACE inhibitor or ARB) for patients with albuminuria and hypertension 1
• Statin therapy for all patients with type 1 or type 2 diabetes and CKD 1
• Consider nonsteroidal mineralocorticoid receptor antagonist for type 2 diabetes patients with persistent albuminuria >30 mg/g (>3 mg/mmol) and normal potassium 1
• Aspirin for secondary prevention in those with established cardiovascular disease 1
• Limit sodium intake to 2,300 mg/day 1

Medication Coordination with Food

For patients on insulin secretagogues (sulfonylureas, glinides):

• Eat moderate amounts of carbohydrate at each meal and snacks 1
• Never skip meals to reduce hypoglycemia risk 1
• Always carry a source of carbohydrates during physical activity 1

For patients on metformin:

• Take medication with food or 15 minutes after a meal if gastrointestinal symptoms persist 1
• Gradually titrate dose to minimize gastrointestinal side effects 1

For patients on α-glucosidase inhibitors:

• Take at start of meal to have maximal effect 1
• If hypoglycemia occurs, use glucose tablets (monosaccharides) rather than complex carbohydrates, as the drug prevents digestion of polysaccharides 1

For patients on GLP-1 receptor agonists:

• Daily or twice-daily formulations should be taken premeal 1
• Once-weekly formulations can be taken at any time regardless of meals 1

For patients on insulin:

• Multiple-daily injection or pump users: take mealtime insulin before eating; meals can be consumed at different times 1
• Premixed insulin users: take insulin at consistent times daily; eat meals at similar times every day; never skip meals 1
• Fixed insulin users: eat similar amounts of carbohydrates each day to match set insulin doses 1
• If physical activity occurs within 1-2 hours of mealtime insulin, lower the dose to reduce hypoglycemia risk 1

Hypoglycemia Treatment

• Use 15-20 g of glucose tablets or carbohydrate-containing foods (fruit juice, sports drinks, regular soda, hard candy) 1
• When blood glucose is 50-60 mg/dL, 15 g of glucose raises levels approximately 50 mg/dL 1
• Recheck blood glucose 15-20 minutes after treatment; repeat if hypoglycemia persists 1

Cost and Access Considerations

• No generic SGLT-2 inhibitors or GLP-1 agonists currently exist; discuss medication costs with patients when selecting specific agents 1, 2, 3
• Prescribe generic medications when available rather than brand-name alternatives 1, 2
• Health systems should assess social risk factors and connect patients to community services 1, 2, 3

Collaborative Care Elements

• Involve clinical pharmacists in medication management to reduce polypharmacy risks 1, 2, 3
• Address sleep health, stress management, and all comorbidities as part of integrated care plans 1, 2
• Use collaborative communication and goal-setting among all team members 1, 2, 3

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Type 1 Diabetes and Youth-Onset Type 2 Diabetes Management

Type 1 Diabetes

Insulin is the cornerstone of type 1 diabetes management, with carbohydrate counting essential for matching mealtime insulin to food intake. 1

• Learn carbohydrate counting or another meal planning approach to quantify carbohydrate intake 1
• Multiple-daily injection or pump therapy allows flexible meal timing 1
• Take mealtime insulin before eating 1

Youth-Onset Type 2 Diabetes

Initial treatment depends on presentation severity and A1C level:

For A1C <8.5% without acidosis or ketosis:

• Start metformin and titrate up to 2,000 mg per day as tolerated 1
• If A1C goals not met, add GLP-1 receptor agonist approved for youth with type 2 diabetes 1
• If still inadequate, initiate or titrate insulin therapy 1

For A1C ≥8.5% without acidosis (with or without ketosis):

• Start long-acting insulin at 0.5 units/kg/day and titrate every 2-3 days based on blood glucose monitoring 1
• Check pancreatic autoantibodies 1
• If autoantibodies negative: continue or start metformin; consider adding GLP-1 receptor agonist if goals not met 1
• If autoantibodies positive: continue or initiate multiple daily injections or pump therapy as for type 1 diabetes; discontinue metformin 1

For diabetic ketoacidosis or hyperosmolar hyperglycemic nonketotic syndrome:

• Manage with intravenous insulin until acidosis resolves, then switch to subcutaneous insulin as for type 1 diabetes 1
• Add metformin after resolution of ketosis/ketoacidosis 1

Metabolic Surgery in Adolescents

• Consider metabolic surgery for adolescents with type 2 diabetes who have BMI >35 kg/m² and elevated A1C and/or serious comorbidities despite lifestyle and pharmacologic intervention 1
• Surgery should only be performed by an experienced surgeon working with a multidisciplinary team including endocrinologist, registered dietitian nutritionist, behavioral health specialist, and nurse 1

Blood Pressure Management in Youth

• Treat elevated blood pressure (90th to <95th percentile for age, sex, and height, or 120-129/<80 mmHg in adolescents ≥13 years) with lifestyle modification focused on healthy nutrition, physical activity, sleep, and weight management 1
• For confirmed hypertension (≥95th percentile), start ACE inhibitors or angiotensin receptor blockers in addition to lifestyle modification 1

Pediatric Use of SGLT-2 Inhibitors

• Empagliflozin 10 mg daily is approved for children aged 10-17 years with type 2 diabetes 4
• Demonstrated A1C reduction of 0.84% compared to placebo with no episodes of severe hypoglycemia 4
• Consider dose escalation to 25 mg if A1C remains ≥7.0% after 12 weeks 4