What are the management strategies for a typical adult patient with diabetes mellitus?

Management of Diabetes Mellitus

All adults with diabetes must begin comprehensive lifestyle modifications immediately—including diabetes self-management education, medical nutrition therapy, and at least 150 minutes weekly of moderate-intensity aerobic activity plus resistance training twice weekly—as these interventions reduce A1C by 0.3-2% and lower mortality risk regardless of medication use. 1, 2, 3

Foundation: Universal Starting Point for All Patients

Lifestyle Interventions (Non-Negotiable First Step)

• Diabetes self-management education and support reduces mortality risk and healthcare costs with high-quality evidence, and must be provided at diagnosis and continuously throughout care 2, 3
• Medical nutrition therapy delivered by a registered dietitian reduces A1C by 0.3-2% in type 2 diabetes and 1.0-1.9% in type 1 diabetes 2, 3
• Physical activity prescription: 150 minutes per week of moderate-intensity aerobic exercise spread over at least 3 days with no more than 2 consecutive days without activity 1, 2
• Resistance training: 2-3 sessions per week on nonconsecutive days 1
• Weight loss: Minimum 5% body weight reduction is mandatory for all overweight/obese patients with type 2 diabetes before or concurrent with pharmacotherapy 2, 3

Monitoring Requirements

• A1C testing every 3 months until target achieved, then every 6 months once stable 4, 3
• Target A1C <7% for most adults to reduce microvascular complications 3
• Blood pressure check at every visit 4
• Self-monitoring of blood glucose plays an essential role in preventing and managing hypoglycemia 5

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Type 2 Diabetes: Stepwise Pharmacologic Algorithm

Step 1: Initial Pharmacotherapy at Diagnosis

Metformin is the mandatory first-line agent due to efficacy, safety, low cost, cardiovascular benefits, and mortality reduction 1, 2, 3

Critical Exception: If the patient has established atherosclerotic cardiovascular disease, heart failure, or chronic kidney disease at diagnosis, immediately add an SGLT2 inhibitor or GLP-1 receptor agonist with proven cardiovascular benefit alongside metformin 1, 3

Step 2: Intensification Based on Comorbidities (If A1C Not at Goal After 3 Months)

For patients with heart failure (reduced or preserved ejection fraction):

• Add SGLT2 inhibitor for glycemic management and prevention of heart failure hospitalizations 1

For patients with chronic kidney disease (eGFR 20-60 mL/min/1.73 m² and/or albuminuria):

• Add SGLT2 inhibitor to minimize CKD progression, reduce cardiovascular events, and reduce heart failure hospitalizations 1
• Note: Glycemic benefits of SGLT2 inhibitors are reduced at eGFR <45 mL/min/1.73 m² 1

For patients with advanced CKD (eGFR <30 mL/min/1.73 m²):

• Add GLP-1 receptor agonist (preferred over SGLT2 inhibitor) for glycemic management due to lower hypoglycemia risk and cardiovascular event reduction 1

For patients without cardiovascular/kidney disease:

• Select agents addressing both individualized glycemic and weight goals 1
• Early combination therapy can be considered at treatment initiation to shorten time to goal attainment 1

Step 3: Injectable Therapy When Needed

GLP-1 receptor agonists (including dual GIP/GLP-1 agonists) are preferred over insulin as the first injectable medication 1, 2

Insulin initiation is indicated regardless of background therapy when: 1

• Evidence of ongoing catabolism (unexpected weight loss)
• Symptoms of hyperglycemia are present
• A1C >10% (>86 mmol/mol) or blood glucose ≥300 mg/dL (≥16.7 mmol/L)

If insulin is used: Combination therapy with a GLP-1 receptor agonist (including dual GIP/GLP-1 agonist) is mandatory for greater glycemic effectiveness, beneficial effects on weight, and reduced hypoglycemia risk 1

Medication Reassessment

• Reevaluate medication plan and adherence every 3-6 months and adjust based on specific factors impacting treatment choice 1, 4
• Never delay intensification when glycemic targets are not met within 3 months 3

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Type 1 Diabetes: Insulin-Based Management

Insulin Regimen (Required from Diagnosis)

Multiple daily insulin injections (≥3 injections daily) or continuous subcutaneous insulin infusion are mandatory from diagnosis 1, 2, 3

Insulin analogues must be used instead of regular human insulin to significantly reduce hypoglycemia risk 1, 2, 3

Automated insulin delivery systems should be considered for all adults with type 1 diabetes 1

Insulin Dosing Education

Patients must receive education on: 1

• Matching mealtime insulin doses to carbohydrate intake, fat, and protein intake
• Modifying insulin dose (correction dose) based on concurrent glycemia and glycemic trends
• Sick-day management
• Anticipated physical activity adjustments

Continuous Glucose Monitoring

Early use of continuous glucose monitoring is recommended for all adults with type 1 diabetes to improve glycemic outcomes, quality of life, and minimize hypoglycemia 1, 2

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Critical Safety Considerations

Hypoglycemia Management

Treat hypoglycemia (glucose <70 mg/dL) with 15-20 grams of rapid-acting glucose, preferably pure glucose 1, 3

Glucagon must be prescribed for all individuals taking insulin or at high risk for hypoglycemia; family and caregivers must know its location and administration 1

Severe or frequent hypoglycemia is an absolute indication for treatment regimen modification 2, 3

For patients with hypoglycemia unawareness: Increase glycemic targets for several weeks to partially reverse unawareness and reduce future episode risk 1, 2

Medication Errors Prevention

• Always check insulin label before each injection to avoid accidental mix-ups between insulin products 5
• Never share MERILOG SoloStar prefilled pens between patients, even if needle is changed 5
• Never share needles or syringes with another person 5

Injection Site Management

• Rotate injection sites within the same region to reduce risk of lipodystrophy and localized cutaneous amyloidosis 5
• Do not inject into areas of lipodystrophy or localized cutaneous amyloidosis 5
• Patients who have repeatedly injected into affected areas must change to unaffected areas and closely monitor for hypoglycemia 5

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Cardiovascular Risk Management

• Initiate at least moderate-intensity statin therapy for most patients aged 40 years or older to reduce cardiovascular mortality 3
• Target blood pressure <140/90 mm Hg for patients with diabetes and hypertension 3
• Initiate ACE inhibitor or ARB (but not both) as first-line antihypertensive for renal protection 3

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Screening for Complications

• Annual comprehensive dilated eye examination by ophthalmologist or optometrist starting immediately at diagnosis 3
• Annual comprehensive foot examination including visual inspection for skin integrity, callous formation, deformities, or ulcers 4
• Annual laboratory monitoring: lipid profile, spot urinary albumin-to-creatinine ratio, serum creatinine and eGFR, liver function tests, thyroid-stimulating hormone, vitamin B12 levels, and serum potassium 4

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Common Pitfalls to Avoid

• Never delay adding SGLT2 inhibitor or GLP-1 receptor agonist in patients with established cardiovascular disease, heart failure, or chronic kidney disease 1, 3
• Never continue aggressive glycemic targets in patients experiencing severe or frequent hypoglycemia 2, 3
• Never neglect ongoing lifestyle modifications throughout the entire treatment course regardless of medication regimen 2, 3
• Never aggressively lower blood pressure below 130/70 mm Hg in older adults due to increased mortality risk 3
• Never overlook psychosocial screening as diabetes-related distress affects 18-45% of patients and significantly impacts self-management 4