Stepwise Management of Diabetes

Foundation: All Patients Start Here

The American College of Physicians recommends that all patients with diabetes begin with comprehensive lifestyle modifications, including diabetes self-management education, medical nutrition therapy, and at least 150 minutes of moderate-intensity aerobic activity weekly, as well as resistance training twice per week 1, 2, 3, 4, 5
Diabetes self-management education and support is associated with improved A1C, reduced mortality risk, and lower healthcare costs, with a strength of evidence rated as high 6, 7
Medical nutrition therapy can reduce A1C by 1.0-1.9% in type 1 diabetes and 0.3-2% in type 2 diabetes, with a moderate strength of evidence 6, 7
Weight loss of at least 5% is recommended for overweight/obese patients with type 2 diabetes, with a high strength of evidence 1, 2, 8

Patients with type 1 diabetes require multiple-dose insulin injections or continuous subcutaneous insulin infusion from diagnosis, with a high strength of evidence 1, 2, 3, 4, 5
Insulin analogues are preferred over regular insulin to reduce hypoglycemia risk, with a moderate strength of evidence 1, 2, 3, 4, 5
Continuous glucose monitoring systems can significantly reduce severe hypoglycemia risk, with a high strength of evidence 1, 2, 3, 4, 5

The American Diabetes Association recommends starting metformin at or soon after diagnosis, along with lifestyle modifications, with a high strength of evidence 1, 2, 3, 4, 5, 8, 9, 10
Metformin is the preferred initial pharmacologic agent due to its efficacy, safety, low cost, and potential cardiovascular benefits, with a high strength of evidence 1, 2, 3, 4, 5, 8, 9, 10
If a patient has established atherosclerotic cardiovascular disease, heart failure, or chronic kidney disease, a GLP-1 receptor agonist or SGLT2 inhibitor should be considered at diagnosis, with a moderate strength of evidence 9, 10

Severe or frequent hypoglycemia is an absolute indication for treatment regimen modification, with a high strength of evidence 1, 2, 3, 5
Patients with hypoglycemia unawareness should increase glycemic targets for several weeks, with a moderate strength of evidence 1, 2, 3, 5
Medication regimens should be reassessed every 3-6 months and adjusted based on A1C, side effects, and patient factors, with a high strength of evidence 9