What is the recommended management and monitoring plan for a patient with type 2 diabetes mellitus (T2DM)?

Management and Monitoring of Type 2 Diabetes Mellitus

For adults with type 2 diabetes, target an HbA1c of <7.0%, fasting glucose 90-130 mg/dL, and postprandial glucose <180 mg/dL, with blood pressure <130/80 mmHg and LDL <100 mg/dL, achieved through a multidisciplinary team approach combining lifestyle interventions with pharmacotherapy. 1

Glycemic Targets

The American Diabetes Association establishes clear numerical goals for glycemic control 1:

• HbA1c: <7.0% (referenced to nondiabetic range of 4.0-6.0%) 1
• Preprandial plasma glucose: 90-130 mg/dL (5.0-7.2 mmol/L) 1
• Peak postprandial plasma glucose: <180 mg/dL (10.0 mmol/L) 1

More stringent targets (HbA1c 6.0-6.5%) are appropriate for patients with short disease duration, long life expectancy, and no significant cardiovascular disease if achievable without hypoglycemia. 1 Conversely, less stringent targets (HbA1c 7.5-8.0%) are indicated for patients with severe hypoglycemia history, limited life expectancy, advanced complications, or extensive comorbidities. 1

Blood Glucose Monitoring

Patients taking insulin or oral glucose-lowering agents must perform blood glucose monitoring to achieve glycemic targets and detect asymptomatic hypoglycemia. 1 For type 1 diabetes, monitoring three or more times daily is recommended, while for type 2 diabetes, frequency should be sufficient to reach glycemic control goals. 1

Critical monitoring considerations 1:

• Ensure patients know whether their monitor provides whole blood or plasma results (plasma values are 10-15% higher than whole blood)
• Time monitoring around meals and medication administration
• Increase frequency during illness or when experiencing hyperglycemia/hypoglycemia symptoms

Cardiovascular and Metabolic Targets

Beyond glucose control, comprehensive management requires 1:

• Blood pressure: <130/80 mmHg 1
• LDL cholesterol: <100 mg/dL (2.6 mmol/l) 1
• Triglycerides: <150 mg/dL (1.7 mmol/l) 1
• HDL cholesterol: >40 mg/dL (1.1 mmol/l) for men; >50 mg/dL for women 1

For patients with triglycerides ≥200 mg/dL, target non-HDL cholesterol (total cholesterol minus HDL) <130 mg/dL. 1

Pharmacologic Management

First-Line Therapy

Metformin is the foundation of pharmacologic therapy for most patients with type 2 diabetes. 2 For patients with established cardiovascular disease, kidney disease, or high cardiovascular risk, initiate GLP-1 receptor agonists or SGLT2 inhibitors early in treatment, even alongside metformin. 2

Severe Hyperglycemia Management

For patients with HbA1c >10% or glucose >300 mg/dL, initiate basal-bolus insulin therapy immediately at 0.3-0.4 units/kg/day, divided approximately half as basal and half as prandial insulin. 3 Continue metformin if renal function permits, as it reduces weight gain and insulin requirements when combined with insulin. 3

Medication Adjustments

When initiating insulin therapy 3:

• Discontinue sulfonylureas to reduce hypoglycemia risk
• Maintain metformin if eGFR permits
• Consider reducing thiazolidinedione doses to avoid edema and excessive weight gain 4

For patients on insulin experiencing hypoglycemia or plasma glucose <100 mg/dL, decrease insulin dose by 10-25%. 5

HbA1c Monitoring Frequency

Perform HbA1c testing initially and at least twice yearly in patients meeting treatment goals. 1 For patients not meeting glycemic targets or with therapy changes, test quarterly. 1 Allow three months after initiating or adjusting therapy before evaluating HbA1c response, unless glycemic control deteriorates. 5

Lifestyle Management

Physical Activity

Prescribe at least 60 minutes of moderate-to-vigorous exercise daily for children and adolescents with type 2 diabetes. 1 For adults, physical activity can reduce HbA1c by 0.4-1.0% and improve cardiovascular risk factors. 2

Define exercise intensity using the "talk test" 1:

• Moderate activity: Can talk but not sing
• Vigorous activity: Cannot talk without pausing for breath

Exercise can be accumulated in shorter increments (10-15 minutes) rather than one continuous session. 1 When initiating aggressive physical activity programs, adjust medication dosages, particularly insulin, to prevent hypoglycemia. 1

Screen Time Reduction

Limit non-academic screen time to maximum 2 hours daily and discourage video screens/televisions in bedrooms. 1 Screen time contributes to sedentary lifestyle and is associated with obesity and increased diabetes risk. 1

Nutritional Management

Conduct a nutritional assessment and provide medical nutrition therapy tailored to individual needs. 1 While no specific diet has proven most effective for improving health outcomes, weight management remains an important treatment component. 2 Modest weight loss of 5-10% contributes meaningfully to improved glucose control. 1

Multidisciplinary Care Team

Diabetes care must be managed by a multidisciplinary team including primary care physicians, subspecialty physicians, nurse practitioners, physician assistants, nurses, dietitians, exercise specialists, pharmacists, dentists, podiatrists, and mental health professionals. 1 The patient must assume an active role in care, with treatment plans formulated collaboratively between patient, family/support persons, and the healthcare team. 1

Medication Timing and Consistency

Patients achieve best outcomes when medications are administered and meals eaten at approximately the same time each day. 1 For insulin users, individualize timing of injections with meals and snacks. 1 Decrease or eliminate the delay between injection and eating if premeal hypoglycemia occurs. 1 Regular exercise should occur at approximately the same time daily when possible. 1

Hypoglycemia Recognition and Management

Train all patients and correctional/facility staff to recognize hypoglycemia symptoms and provide prompt treatment. 1 Document history of severe hypoglycemia requiring assistance of another person. 1 Appropriate staff should be trained to administer glucagon. 1

For conscious patients with hypoglycemia, administer 15-20g of glucose or carbohydrate-containing food, monitor blood glucose every 15 minutes until normalization, then provide a meal or snack to prevent recurrence. 6

Special Populations

Patients with Heart Failure

For patients with type 2 diabetes and NYHA Class II-III heart failure, initiate pioglitazone at the lowest approved dose only if prescribed, with gradual dose escalation after several months and careful monitoring for weight gain, edema, or CHF exacerbation. 5 Pioglitazone is not recommended for NYHA Class III-IV cardiac status. 5

Patients on Insulin

In patients receiving insulin, monitor for fluid retention and heart failure symptoms when adding thiazolidinediones. 5 In clinical trials, 1.1% of patients on pioglitazone plus insulin developed congestive heart failure compared to none on insulin alone. 5

Documentation Requirements

Clearly document all conversations pertaining to lifestyle modifications, medication adjustments, and self-management education in the patient's medical record. 1

Long-Term Outcomes

Intensive glucose-lowering strategies (HbA1c <7%) produce absolute reductions in microvascular disease (3.5%), myocardial infarction (3.3-6.2%), and mortality (2.7-4.9%) two decades after trial completion. 2 SGLT2 inhibitors and GLP-1 receptor agonists demonstrate 12-26% risk reduction for atherosclerotic cardiovascular disease, 18-25% for heart failure, and 24-39% for kidney disease over 2-5 years. 2