Type 2 Diabetes Treatment
Adults with type 2 diabetes should begin metformin immediately at diagnosis alongside lifestyle modifications, with SGLT2 inhibitors or GLP-1 receptor agonists added early if cardiovascular or kidney disease is present or cardiovascular risk is high. 1, 2
Initial Pharmacological Therapy
Metformin is the preferred first-line medication for all adults with type 2 diabetes unless contraindicated or not tolerated. 1 This should be initiated at or soon after diagnosis, even while lifestyle modifications are being implemented. 1
For patients with newly diagnosed diabetes presenting with marked symptoms (polyuria, polydipsia, weight loss) or A1C ≥10-12%, initiate insulin therapy immediately (basal insulin 10 units or 0.1-0.2 units/kg daily at bedtime) combined with metformin. 3
For patients with established cardiovascular disease, heart failure, chronic kidney disease, or at high cardiovascular risk, add an SGLT2 inhibitor or GLP-1 receptor agonist to metformin as early combination therapy—these agents reduce cardiovascular events by 12-26%, heart failure by 18-25%, and kidney disease progression by 24-39% over 2-5 years. 2
Lifestyle Modifications (Foundational and Ongoing)
Physical Activity Requirements
All adults with type 2 diabetes must engage in at least 150 minutes per week of moderate-to-vigorous intensity aerobic activity, spread over at least 3 days with no more than 2 consecutive days without activity. 1, 4
Add resistance exercise 2-3 sessions per week on nonconsecutive days, involving major muscle groups. 1, 4
Break up prolonged sitting every 30 minutes for blood glucose benefits—sedentary behavior reduction is critical. 1, 4
Physical activity reduces A1C by 0.4-1.0% and improves cardiovascular risk factors including hypertension and dyslipidemia. 2
For younger or more physically fit individuals, 75 minutes per week of vigorous-intensity exercise may suffice. 1
Nutrition Therapy
Every patient with type 2 diabetes should receive individualized medical nutrition therapy from a registered dietitian, which reduces A1C by 0.3-2.0%. 1
Focus on a heart-healthy dietary pattern with calorie restriction to achieve weight loss if overweight or obese. 1
Limit sodium intake to <2,300 mg/day (not below 1,500 mg/day even with hypertension). 1
Achieve a 500-750 kcal/day energy deficit through reduced calorie intake combined with increased physical activity. 1
No single diet has proven superior for health outcomes, but adherence to any structured eating pattern that creates caloric deficit is effective. 2
Weight Management
Target modest weight loss of 5-10% of body weight, which delays diabetes progression and improves glycemic control, blood pressure, and lipid levels. 1, 5
Weight loss interventions should be intensive with frequent follow-up to achieve and maintain reductions. 1
Even moderate weight loss improves insulin sensitivity and glycemic control. 5
Calculate BMI annually or more frequently to monitor progress. 1
Medication Escalation Strategy
When metformin alone fails to achieve A1C targets:
Add SGLT2 inhibitor or GLP-1 receptor agonist if cardiovascular/kidney disease present or high cardiovascular risk—these provide cardioprotective and renoprotective benefits beyond glucose lowering. 1, 2
High-potency GLP-1 receptor agonists and dual GIP/GLP-1 receptor agonists produce >5% weight loss in most patients, often exceeding 10%. 2
Alternative add-on options include DPP-4 inhibitors, sulfonylureas, or thiazolidinediones, though these lack the cardiovascular/renal benefits. 1, 2
Insulin Therapy Initiation
Approximately one-third of patients with type 2 diabetes require insulin during their lifetime. 2
When A1C remains above target despite oral agents, or if A1C ≥10-12% with symptoms, initiate basal insulin at 10 units or 0.1-0.2 units/kg daily at bedtime, combined with metformin. 3
Titrate basal insulin by 2 units every 3 days until fasting glucose reaches 80-130 mg/dL. 3
If A1C remains above target after optimizing basal insulin, add mealtime rapid-acting insulin starting with 4 units before the largest meal, or consider adding a GLP-1 receptor agonist instead. 3
Monitor for hypoglycemia and reduce dose by 10-20% if glucose <70 mg/dL occurs. 3
Glycemic Targets
Target A1C <7% for most adults to reduce microvascular complications (absolute risk reduction 3.5%), myocardial infarction (3.3-6.2%), and mortality (2.7-4.9%). 2
- Intensive glucose control provides sustained benefits extending 2 decades after initial treatment. 2
Cardiovascular Risk Management
For adults with type 2 diabetes aged 40-75 years, initiate moderate-intensity statin therapy regardless of baseline cardiovascular risk. 1
For those with multiple cardiovascular risk factors, high-intensity statin therapy is reasonable to reduce LDL-C by 50% or more. 1
Target blood pressure and lipid goals alongside glycemic control. 1
Critical Monitoring
Measure A1C every 3 months until target achieved, then at least twice yearly. 3
Monitor for vitamin B12 deficiency periodically in patients taking metformin, particularly those with anemia. 1
Screen regularly for diabetic complications including retinopathy, nephropathy (microalbuminuria), neuropathy, and foot problems. 6
Common Pitfalls to Avoid
Do not delay metformin initiation—it should begin at diagnosis, not after failed lifestyle modification alone. 1
Do not use sliding scale regular insulin as long-term therapy—this is only temporary while establishing proper basal insulin dosing. 3
Do not allow more than 2 consecutive days without exercise—this diminishes acute insulin-sensitizing effects. 1, 4
Do not restrict sodium below 1,500 mg/day even with hypertension, as this is generally not beneficial and difficult to maintain. 1
Do not overlook cardiovascular/renal protective medications—SGLT2 inhibitors and GLP-1 receptor agonists should be prioritized in appropriate patients, not reserved as last-line therapy. 2