Type 2 Diabetes Management 2024: Guidelines and Treatment Options

Introduction

Initial Evaluation

In the initial evaluation of a patient with suspected diabetes, confirm the diagnosis using HbA1c, fasting plasma glucose (FPG), and/or 2-hour plasma glucose (2h-PG) during an oral glucose tolerance test (OGTT). Assess the presence of comorbidities such as hypertension, dyslipidemia, cardiovascular disease (CVD), and chronic kidney disease (CKD). Additionally, evaluate the patient for complications related to diabetes, including retinopathy, nephropathy, and neuropathy.

Diagnosis

• Fasting Plasma Glucose (FPG) ≥ 126 mg/dL.
• 2-hour Plasma Glucose ≥ 200 mg/dL during an oral glucose tolerance test (OGTT).
• Hemoglobin A1c (HbA1c) ≥ 6.5%.
• Random Plasma Glucose ≥ 200 mg/dL with classic symptoms of hyperglycemia.

Management

1. Initial Diagnosis of T2DM

• Confirm diagnosis: A1C ≥ 6.5% or fasting glucose ≥ 126 mg/dL.
• Lifestyle interventions:
  • Encourage weight loss (≥ 7% body weight).
  • Exercise: ≥ 150 minutes/week moderate intensity or ≥ 75 minutes vigorous exercise.
  • Dietary adjustments: Low-fat, low-carb diet (tailored to individual needs).

2. Set Individualized A1C Goals

• < 7%: For most adults under 65 without comorbidities.
• 7.5-8%: For older adults or those with multiple comorbidities, high risk of hypoglycemia, or reduced life expectancy.

3. First-Line Therapy: Metformin

• Start Metformin (if no contraindications):
  • Dose: 500 mg once daily, titrate up to 2000 mg daily based on tolerance.
  • Contraindications: eGFR < 30 mL/min/1.73 m², significant hepatic impairment, or acute/chronic metabolic acidosis.
  • Adverse effects: GI intolerance, vitamin B12 deficiency.
• If A1C remains above goal after 3 months of lifestyle and metformin therapy: Go to step 4. Add-on Therapy Based on Comorbidities!

4. Add-on Therapy Based on Comorbidities

• Cardiovascular Disease (CVD), Heart Failure (HF), or Chronic Kidney Disease (CKD)
  • Preferred: SGLT-2 inhibitors or GLP-1 receptor agonists:
    • SGLT-2 inhibitors (Empagliflozin, Canagliflozin, Dapagliflozin):
      • Cardioprotective, reduces HF hospitalizations, CKD progression.
      • Contraindications: eGFR < 30 mL/min/1.73 m².
      • Adverse effects: UTIs, mycotic infections, euglycemic DKA.
    • GLP-1 receptor agonists (Semaglutide, Dulaglutide, Liraglutide):
      • Cardioprotective, promotes weight loss.
      • Contraindications: History of medullary thyroid carcinoma, MEN2.
      • Adverse effects: GI upset, pancreatitis risk.
• No Cardiovascular or Renal Disease:
  • Consider any of the following based on patient needs and tolerability:
    • DPP-4 inhibitors (Sitagliptin, Linagliptin, Saxagliptin):
      • Low risk of hypoglycemia, weight neutral.
      • Adverse effects: Pancreatitis, risk of heart failure (Saxagliptin, Alogliptin).
    • Sulfonylureas (Glipizide, Glyburide):
      • Low cost, potent A1C reduction.
      • Adverse effects: Hypoglycemia, weight gain.
    • Thiazolidinediones (Pioglitazone):
      • Effective for insulin resistance, improves nonalcoholic steatohepatitis.
      • Adverse effects: Weight gain, fluid retention, fracture risk.
      • Contraindications: NYHA class III/IV heart failure.
    • Meglitinides (Repaglinide):
      • Useful for postprandial hyperglycemia.
      • Adverse effects: Hypoglycemia, weight gain.

5. Monitor and Adjust Therapy

• Assess A1C every 3 months to determine if therapy adjustments are needed.
• Consider continuous glucose monitoring for patients with high hypoglycemia risk or poor control.

6. Consider Insulin Therapy (if noninsulin therapy fails)

• Add basal insulin or consider combination therapy if A1C remains above target despite maximal doses of noninsulin agents.

7. Patient Education and Support

• Address social determinants of health: Ensure access to medications and monitoring, especially in low-income or underserved populations.
• Provide diabetes education and emphasize the importance of adherence to lifestyle modifications.

References

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