Diabetes Management

Diagnostic Criteria

A fasting glucose of ≥126 mg/dL meets the diagnostic threshold for diabetes, while 100-125 mg/dL is considered prediabetes, according to the American College of Physicians 1

At least 150 minutes of moderate-intensity aerobic activity weekly, including resistance training twice weekly, and reducing sedentary time is recommended, as suggested by the American Heart Association 1
A comprehensive dietary approach should include:
Exercise improves insulin sensitivity independent of weight loss, and moderate to high-intensity exercise is more effective than low-intensity exercise, as found in studies published in the Diabetes Care journal 3, 6, 7
Combining dietary changes with physical activity is more effective for weight loss than relying on either approach alone, as suggested by studies published in the Diabetes Care journal 3, 4, 5
Weight management is crucial for improving insulin sensitivity, with even modest weight loss (5-7% of initial body weight) significantly improving insulin resistance in overweight and obese individuals, as reported by the Diabetes Care journal 3

Metformin is the preferred initial pharmacologic agent for newly diagnosed type 2 diabetes, as recommended by the American Diabetes Association 1, 8, 7, 9, 10, 11, 12
The initial dose of metformin should be low (500 mg once or twice daily) to minimize gastrointestinal side effects, with a gradual titration up to an effective dose of 1,000-2,000 mg daily in divided doses, according to the European Association for the Study of Diabetes 13
SGLT2 inhibitors are recommended for patients with type 2 diabetes, CKD, and eGFR ≥20 ml/min/1.73 m², and can be initiated regardless of baseline HbA1c or metformin use, as recommended by the American Diabetes Association 14, 15
GLP-1 receptor agonists with proven cardiovascular benefit are recommended for patients who cannot use SGLT2 inhibitors, or can be added to SGLT2 inhibitors for additional glycemic control, as recommended by the American Diabetes Association 14, 10, 12, 16, 17, 18
Thiazolidinediones, such as Pioglitazone, reduce the risk of stroke, myocardial infarction, and diabetes in patients with insulin resistance, as seen in the IRIS trial, but may have potential side effects including weight gain, edema, and fractures 19

HbA1c should be checked every 3 months until target is achieved, then at least every 6 months, as recommended by the American Diabetes Association 13
For HbA1c <9%, a second agent should be added based on patient characteristics, considering SGLT2 inhibitors or GLP-1 receptor agonists, particularly if cardiovascular disease or CKD is present, according to the American College of Cardiology 1, 8
For HbA1c ≥9%, initial dual therapy with metformin plus a second agent should be considered, as suggested by the European Association for the Study of Diabetes 8
The presence of cardiovascular disease, heart failure, or CKD should influence medication selection, as recommended by the American Heart Association 8
Patient education should provide diabetes self-management education and support, according to the American Diabetes Association 1
Frequent self-monitoring of blood glucose is recommended, with targets of fasting glucose <130 mg/dL and postprandial glucose <180 mg/dL, as recommended by the American Diabetes Association 7
Regular assessment of glycemia, albuminuria, blood pressure, cardiovascular risk, and lipids every 3-6 months, as recommended by the American Diabetes Association 14

Blood pressure, lipids, and aspirin therapy should be managed as appropriate to address cardiovascular risk factors, as recommended by the American College of Cardiology 1
Insulin resistance management involves a combination of lifestyle modifications and pharmacological interventions, with the goal of improving insulin sensitivity and reducing the risk of cardiovascular disease, as recommended by the American Diabetes Association 3, 4, 2, 7, 14, 10
Moderate-intensity statin is recommended for all patients with diabetes and CKD for primary prevention of ASCVD, as recommended by the American Diabetes Association 14
High-intensity statin is recommended for patients with known ASCVD or multiple ASCVD risk factors, as recommended by the American Diabetes Association 14
Consider ezetimibe, PCSK9 inhibitors, or icosapent ethyl based on ASCVD risk and lipid levels, as recommended by the American Diabetes Association 14

Relying solely on standard weight reduction diets without structured support programs is a common pitfall in treating insulin resistance, as recommended by the American Diabetes Association 4, 2
Using very low calorie diets without a structured weight maintenance program is also a common pitfall, as recommended by the American Diabetes Association 4, 2
Therapeutic inertia, or failing to intensify therapy despite suboptimal control, should be avoided, as recommended by the American Diabetes Association 14
Neglecting comorbidities, such as ASCVD, heart failure, or CKD, in medication selection should be avoided, as recommended by the American Diabetes Association 14, 10
Overemphasis on glycemic control alone, without addressing other cardiovascular risk factors, should be avoided, as recommended by the American Diabetes Association 14
Overlooking vitamin B12 deficiency in long-term metformin users should be avoided, as recommended by the American Diabetes Association 9