What is the recommended treatment plan for a patient with diabetes?

Recommended Treatment Plan for Diabetes

All patients with diabetes should begin with comprehensive lifestyle modifications including diabetes self-management education, medical nutrition therapy, and at least 150 minutes of moderate-intensity aerobic activity weekly plus resistance training twice per week, combined with metformin as first-line pharmacologic therapy for type 2 diabetes (unless contraindicated or insulin is immediately required). 1, 2

Foundation: Universal Starting Point for All Patients

Lifestyle Modifications (Required for All)

• Diabetes self-management education and support reduces A1C, mortality risk, and healthcare costs and should be initiated at diagnosis 1, 2
• Medical nutrition therapy can reduce A1C by 0.3-2% in type 2 diabetes and 1.0-1.9% in type 1 diabetes 1, 3
• Physical activity prescription includes at least 150 minutes per week of moderate-intensity aerobic exercise plus resistance training at least twice weekly 1, 2, 3
• Weight loss of at least 5% is recommended for all overweight/obese patients with type 2 diabetes, as this level of weight reduction was associated with a 58% reduction in diabetes progression risk 1, 3

Nutrition Therapy Specifics

• Reduce overall carbohydrate intake, as this demonstrates the most evidence for improving glycemia 3
• Restrict calorie intake to approximately 1500 kcal per day for weight loss 3
• Limit fat intake to 30-35% of total daily energy, with 10% from monounsaturated fatty acids 3
• Avoid trans-fats completely 3
• No single macronutrient distribution is ideal; individualize based on current eating patterns while prioritizing carbohydrate reduction 3

Type 2 Diabetes: Stepwise Pharmacologic Algorithm

Step 1: Initial Pharmacologic Therapy

Start metformin at or soon after diagnosis along with lifestyle modifications 1, 2, 4. Metformin is preferred due to efficacy, safety, low cost, and potential cardiovascular benefits 1, 2.

• Begin with low dose and increase gradually to maximum tolerated dose of 2000 mg daily in divided doses 2
• Continue metformin even when adding second agents unless contraindicated 4
• Metformin can be continued with declining renal function down to eGFR 30-45 mL/min with dose reduction 4

Critical Exception - Start Insulin Instead of Metformin When:

• Ketosis or diabetic ketoacidosis present 2
• Random blood glucose ≥250 mg/dL 2
• HbA1c >8.5% 2
• Symptomatic diabetes with polyuria, polydipsia, and weight loss 2

Step 2: Adding Second Agent (After 3 Months on Maximum Metformin)

Add SGLT-2 inhibitor or GLP-1 receptor agonist when HbA1c remains above target after 3 months of maximized metformin therapy 4, 1.

Prioritize SGLT-2 inhibitors when:

• Heart failure is present (reduces hospitalization for heart failure) 4
• Chronic kidney disease is present (reduces progression of CKD) 4
• Reducing all-cause mortality and major adverse cardiovascular events is the goal 4

Prioritize GLP-1 receptor agonists when:

• Increased stroke risk exists 4
• Weight loss is an important treatment goal 4
• Reducing all-cause mortality and major adverse cardiovascular events is the goal 4

Special Circumstances at Diagnosis:

• If established atherosclerotic cardiovascular disease, heart failure, or chronic kidney disease exists, consider adding GLP-1 receptor agonist or SGLT-2 inhibitor at diagnosis alongside metformin 1
• If HbA1c ≥9% at diagnosis, start dual therapy immediately rather than waiting for metformin monotherapy to fail 4
• If HbA1c ≥10% or blood glucose is high with symptoms, initiate basal insulin with or without metformin 4

Step 3: Alternative Options

Do NOT use DPP-4 inhibitors as first-line add-on therapy given lack of mortality/morbidity benefit (strong recommendation, high-certainty evidence) 4.

Other options with less robust mortality/morbidity data include:

• Thiazolidinediones 2
• Basal insulin when HbA1c is very high or catabolic features present 4

Type 1 Diabetes Management

Initiate multiple-dose insulin injections (≥3 injections daily) or continuous subcutaneous insulin infusion from diagnosis 1, 2.

• Use insulin analogs rather than regular insulin to reduce hypoglycemia risk 1
• Educate patients on matching prandial insulin doses to carbohydrate intake, preprandial blood glucose levels, and anticipated activity 2
• Continuous glucose monitoring systems significantly reduce severe hypoglycemia risk and should be strongly considered 1, 2
• Most patients require both basal and bolus insulin components 1

Glycemic Targets and Monitoring

• Target HbA1c <7% for most adults with diabetes 2
• More stringent targets (such as <6.5%) appropriate for selected individuals without significant hypoglycemia risk 2, 3
• Less stringent targets appropriate for those with severe comorbidities, limited life expectancy, or advanced disease 3, 2
• Monitor HbA1c every 3 months until target reached, then at least twice yearly 2
• For critically ill hospitalized patients: target glucose 140-180 mg/dL 3
• For non-critically ill hospitalized patients: premeal glucose <140 mg/dL and random glucose <180 mg/dL 3

Hypoglycemia Management and Prevention

Immediate treatment: 15-20g of rapid-acting glucose, recheck blood glucose after 15 minutes, repeat if hypoglycemia persists 2.

Prevention strategies:

• Severe or frequent hypoglycemia requires immediate modification of treatment regimens 1, 2
• Patients with hypoglycemia unawareness should increase glycemic targets temporarily for several weeks to partially reverse this condition 1, 2
• Do not continue sulfonylureas or long-acting insulin at full doses when adding SGLT-2 inhibitors or GLP-1 agonists due to severe hypoglycemia risk 4
• Educate patients about situations increasing hypoglycemia risk: fasting, exercise, sleep 2

Common Pitfalls to Avoid

• Never use DPP-4 inhibitors as first-line add-on therapy - they lack mortality and morbidity benefits compared to SGLT-2 inhibitors and GLP-1 agonists 4
• Do not aggressively target near-normal HbA1c in patients with advanced disease where such targets cannot be safely reached 2
• Self-monitoring of blood glucose may be unnecessary with metformin plus SGLT-2 inhibitor or GLP-1 agonist since these combinations carry no hypoglycemia risk 4
• Do not delay insulin initiation in type 1 diabetes or in type 2 diabetes with severe hyperglycemia and catabolic features 2
• Avoid overtreating older adults - many maintain HbA1c <7% and are unnecessarily treated with insulin or sulfonylureas, increasing hypoglycemia risk 3

Special Populations

Older Adults (≥80 years)

• Are more than twice as likely to visit emergency departments for insulin-related hypoglycemia 3
• Many are overtreated with half maintaining HbA1c <7% while on insulin or sulfonylurea 3
• Consider oral therapy in place of insulin when appropriate to lower hypoglycemia risk 3

Children and Adolescents with Type 2 Diabetes

• Initial management includes lifestyle modifications and diabetes education with metformin as initial therapy for A1C <8.5% without acidosis or ketosis 2
• For A1C ≥8.5% or with ketosis, initiate insulin therapy until acidosis resolves 2