Type 2 Diabetes Management

Introduction to Type 2 Diabetes Management

The American Diabetes Association recommends metformin as the first-line medication for type 2 diabetes due to its effectiveness (A1C reduction of 1.0-1.5%), safety, low cost, and potential to reduce cardiovascular events and death 1
Metformin decreases hepatic glucose production and improves insulin sensitivity, with a maximum daily dose of 2000-2550mg 1

For patients with established ASCVD, heart failure, or CKD, the American Diabetes Association recommends adding an SGLT2 inhibitor with proven cardiovascular benefit (empagliflozin, canagliflozin, dapagliflozin) as second-line therapy 2, 3
For patients needing greater weight loss, the American Diabetes Association recommends adding a GLP-1 RA (semaglutide preferred for efficacy) as second-line therapy 4
For patients with cost concerns or minimal comorbidities, the American Diabetes Association suggests considering a sulfonylurea (glimepiride preferred for lower hypoglycemia risk) as second-line therapy 4

SGLT2 inhibitors can reduce A1C levels by 0.7-1.0% and have demonstrated cardiovascular benefits 2, 3
Empagliflozin reduces major adverse cardiovascular events (MACE) by 14% (HR 0.86; 95% CI 0.74-0.99) in patients with type 2 diabetes and established cardiovascular disease 5
Empagliflozin reduces cardiovascular death by 38% (HR 0.62; 95% CI 0.49-0.77) in patients with type 2 diabetes and established cardiovascular disease 5
Empagliflozin reduces hospitalization for heart failure by 35% in patients with type 2 diabetes and established cardiovascular disease 6
Benefits extend to patients with heart failure with preserved ejection fraction (HFpEF), showing a 21% reduction in the composite outcome of cardiovascular death or hospitalization for heart failure 6

GLP-1 RAs can reduce A1C levels by 1.0-1.8% (semaglutide highest) and have demonstrated cardiovascular benefits 4

Empagliflozin is now approved for use in children aged 10-17 years with type 2 diabetes, showing significant A1C reduction compared to placebo, as recommended by the American Diabetes Association 7

When adding empagliflozin to patients taking insulin or sulfonylureas, consider reducing doses of these medications by 20-50% to reduce hypoglycemia risk, as recommended by the Journal of the American College of Cardiology 8
Monitor blood glucose and HbA1c, and adjust other diabetes medications if needed to prevent hypoglycemia 8

The American Heart Association notes that SGLT2 inhibitors and GLP-1 RAs have shown cardiovascular benefits, while DPP-4 inhibitors are generally neutral for cardiovascular outcomes 2
Dapagliflozin reduces the risk of the primary outcome (worsening heart failure or cardiovascular death) by 26% (HR 0.74 [95% CI 0.65–0.85]) in the DAPA-HF study, and by 18% in the DELIVER study for patients with heart failure with preserved ejection fraction (HFpEF) 5
SGLT2 inhibitors reduce cardiovascular mortality, hospitalization for heart failure, promote weight loss, lower blood pressure, and have a low hypoglycemia risk, according to the American Heart Association 9

The combination of diltiazem (calcium channel blocker) and empagliflozin (SGLT2 inhibitor) can be safely used together in patients with type 2 diabetes and hypertension, providing complementary cardiovascular benefits 5
The American College of Cardiology recommends targeting blood pressure <130/80 mmHg in patients with diabetes, which can be achieved with the combination of diltiazem and empagliflozin 10

SGLT2 inhibitors like empagliflozin may cause a modest initial decrease in eGFR that is typically hemodynamically mediated and reversible, as reported by the Journal of the American College of Cardiology 8
Monitor renal function in the first several weeks of therapy, particularly in patients with impaired baseline renal function, and adjust dosing according to renal function guidelines 8

SGLT2 inhibitors may increase the risk of genital mycotic infections and euglycemic diabetic ketoacidosis 8
Hypoglycemia risk is highest with insulin and sulfonylureas, while metformin, SGLT2 inhibitors, DPP-4 inhibitors, and GLP-1 RAs have a minimal risk of hypoglycemia when used as monotherapy 1, 2, 3, 4