Initial Management of Type 2 Diabetes Mellitus

Lifestyle Modifications

The American Diabetes Association recommends that all patients with type 2 diabetes should receive comprehensive diabetes self-management education that is culturally appropriate and focuses on healthy eating patterns and physical activity 2, 3
Patients with overweight or obesity should be provided with developmentally appropriate lifestyle programs aimed at achieving at least a 7-10% decrease in excess weight 2, 3
Physical activity recommendations include at least 60 minutes of moderate to vigorous physical activity daily with muscle and bone strengthening exercises at least 3 days per week 2
Nutrition should focus on healthy eating patterns emphasizing nutrient-dense, high-quality foods and decreased consumption of calorie-dense, nutrient-poor foods, particularly sugar-added beverages 2, 3

The American College of Cardiology recommends metformin as first-line pharmacologic therapy for type 2 diabetes, unless specific circumstances require insulin initiation 1
Metformin should be initiated at or soon after diagnosis if not contraindicated, starting at a low dose of 500 mg daily, increasing by 500 mg every 1-2 weeks, up to an ideal maximum dose of 2000 mg daily in divided doses 1
Common side effects of metformin include gastrointestinal symptoms, which are often transient 4

Insulin therapy should be initiated instead of metformin as first-line treatment in patients with ketosis or diabetic ketoacidosis, random blood glucose ≥250 mg/dL, HbA1c >8.5%, or symptomatic hyperglycemia 1, 2, 3

A reasonable HbA1c goal for most adults with type 2 diabetes is <7% 2, 3
More stringent targets, such as <6.5%, may be appropriate for selected individuals if achievable without significant hypoglycemia 2, 3
Glycemic status should be assessed at least every 3 months 2, 3
Self-monitoring of blood glucose might be unnecessary in patients receiving metformin alone 5

If glycemic targets are not met with metformin and lifestyle modifications, consider adding an SGLT-2 inhibitor or GLP-1 receptor agonist, particularly in patients with cardiovascular or kidney disease 5
SGLT-2 inhibitors reduce the risk for all-cause mortality, major adverse cardiovascular events, progression of chronic kidney disease, and hospitalization due to heart failure 5
GLP-1 receptor agonists reduce the risk for all-cause mortality, major adverse cardiovascular events, and stroke 5
The American College of Physicians recommends against adding a DPP-4 inhibitor to metformin 5

Delaying treatment intensification when glycemic targets are not met can lead to poor outcomes, and should be avoided 1
Failing to adjust medications during periods of acute illness or procedures can also lead to poor outcomes, and should be avoided 1
Not recognizing the difference between type 1 and type 2 diabetes, especially in children and adolescents with obesity, can lead to inappropriate treatment, and should be avoided 2, 4

For children and adolescents with type 2 diabetes, the approach is similar but requires age-appropriate considerations, including comprehensive diabetes self-management education and lifestyle modifications 2, 3, 4
In youth with newly diagnosed type 2 diabetes with poor glycemic control but without ketosis, short-term insulin therapy may be beneficial 4
Many pediatric patients with type 2 diabetes can be weaned gradually from insulin therapy and subsequently managed with metformin and lifestyle modification 4