Diabetes Treatment Guidelines

Oral Pharmacologic Treatment for Type 2 Diabetes

Metformin as First-Line Therapy

The American College of Physicians (ACP) strongly recommends prescribing metformin as the initial pharmacologic therapy for adults with type 2 diabetes when lifestyle modifications such as diet and exercise fail to adequately control hyperglycemia . Metformin is favored due to its effectiveness in lowering hemoglobin A1c (HbA1c) levels, weight, and systolic blood pressure, along with its relatively low cost and favorable safety profile.

Adding a Second Oral Agent

When metformin alone does not achieve glycemic control, the ACP suggests adding a second oral agent. Options include sulfonylureas, thiazolidinediones, sodium-glucose cotransporter-2 (SGLT-2) inhibitors, or dipeptidyl peptidase-4 (DPP-4) inhibitors. The choice of the second agent should be based on a discussion between the clinician and patient regarding the benefits, adverse effects, and costs of each medication .

Insulin Therapy in Type 2 Diabetes

Indications for Insulin

Insulin therapy is recommended for type 2 diabetes patients who do not achieve glycemic targets with oral medications, particularly those with HbA1c levels ≥7.5% or ≥10%. Insulin can be initiated as basal insulin or premixed formulations, and rapid-acting insulin can be added to control postprandial glucose levels if necessary.

Combination with Oral Agents

Combining insulin with oral agents like metformin can reduce insulin doses, minimize weight gain, and lower the risk of hypoglycemia. This combination approach is particularly useful in achieving better glycemic control while mitigating some of the adverse effects associated with insulin therapy alone.

Special Considerations for Older Adults

Frail Older Adults

For frail older adults with type 2 diabetes, the Diabetes Care Program of Nova Scotia (DCPNS) and the Palliative and Therapeutic Harmonization (PATH) program recommend maintaining HbA1c levels at or above 8% to avoid hypoglycemic events, which can be particularly harmful in this population. Simplified treatment regimens, such as using basal insulin alone, are advised to accommodate the variable oral intake often seen in frail older adults.

Avoiding Intensive Glycemic Control

In older adults, especially those with multiple comorbidities or limited life expectancy, less stringent HbA1c targets (e.g., <8%) are appropriate to balance the benefits of glycemic control with the risks of hypoglycemia and other adverse effects.

Continuous Glucose Monitoring and Insulin Infusion

Continuous Glucose Monitoring (CGM)

The Endocrine Society recommends CGM for adults with diabetes, particularly those using intensive insulin regimens. CGM can help lower HbA1c levels and reduce the frequency of hypoglycemic episodes by providing real-time glucose data and trends. Proper education and support are essential for the effective use of CGM technology.

Continuous Subcutaneous Insulin Infusion (CSII)

CSII, or insulin pump therapy, is recommended for patients with type 1 diabetes and selected patients with type 2 diabetes who require intensive insulin therapy. This method allows for more precise insulin delivery and can improve glycemic control while reducing the risk of hypoglycemia.

Conclusion

The treatment of diabetes, particularly type 2 diabetes, involves a combination of lifestyle modifications and pharmacologic interventions. Metformin remains the first-line therapy, with additional oral agents or insulin therapy considered based on individual patient needs. Special considerations are necessary for older adults and those with frailty to avoid adverse effects. Continuous glucose monitoring and insulin infusion technologies offer advanced options for managing diabetes, particularly in patients requiring intensive insulin therapy. These guidelines aim to optimize glycemic control while minimizing risks and improving overall patient outcomes.

Diabetes treatment guidelines

Summary

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