Essential elements of the management plan
Glycemic control,
Medical nutrition therapy (MNT),
Diabetes self-management education,
Physical activity, and
Psychosocial assessment and care
The target A1C goal is
6.5% or less
<7% for most nonpregnant adults and
<7.5% for pediatric patient
2. Treatment Summary
Patients should take an active role in their own care.
Essential elements of the management plan
• Glycemic control,
• Medical nutrition therapy (MNT),
• Diabetes self-management education,
• Physical activity, and
• Psychosocial assessment and care
3. Treatment Summary
The target A1C goal is
•6.5% or less
•<7% for most nonpregnant adults and
•<7.5% for pediatric patient
4. Treatment Summary- Type I
Most patients with Type
1 diabetes need to take
insulin multiple times a
day. This typically
involves 3 to 4 injections
daily.
01
The injections include
two types of insulin:
"basal" (long-acting) and
"prandial" (mealtime).
02
Another option is
continuous subcutaneous
(subQ) insulin infusion.
This is often done with
an insulin pump, which
provides a steady flow of
insulin into the body.
03
5. Treatment Summary- Type I
Insulin "analogs" are often
recommended. These are
modified forms of insulin
that work more like
natural human insulin.
These analogs are
especially suggested for
patients who have a high
risk of low blood sugar, or
"hypoglycemia."
6. Treatment Summary- Type II
The initial treatment
includes changes to
lifestyle to help with
weight loss and increase
physical activity.
01
Metformin is the first-
choice medicine for
treating Type 2 Diabetes,
especially for those
recently diagnosed or
with an A1C below 7.5%.
02
If a patient's A1C is 7.5%
or higher, or 9% or
higher, they should start
a dual therapy.
03
This includes metformin
(or another first-line
agent) and another
medicine, along with
lifestyle changes.
04
7. Treatment Summary- Type II
For patients who also have arteriosclerotic cardiovascular
disease (hardening of the arteries), the second medicine should
be one that reduces cardiovascular risk.
Some options include empagliflozin, liraglutide, or canagliflozin.
The choice will depend on the specifics of the drug and patient
factors.
8. Treatment
Summary- Type II
If metformin or an
alternative
medication doesn't
help reach or
maintain the target
A1C after 3 months,
Additional drugs
GLP-1 receptor
agonists
SGLT2 inhibitors
DPP-4 inhibitors
Thiazolidinediones
Basal insulin
Colsevelam
Bromocriptine QR
Alpha-glucosidase
inhibitors
Sulfonylureas
Glinides
9. Drug Therapy-
Type I
Diabetes
Mellitus
Question: How should most patients with type 1 diabetes,
including children and adolescents, be treated?
Answer: Most patients with type 1 diabetes, including
children and adolescents, should be treated with multiple-
dose insulin injections (3 to 4 injections/day of basal and
prandial insulin) or continuous subcutaneous insulin
infusion.
Question: What are insulin analogs recommended for?
Answer: Insulin analogs are recommended for most
patients with type 1 diabetes, especially those who have
an increased risk of hypoglycemia.
Question: What factors should be considered when
deciding the amount of prandial insulin to be administered?
Answer: The amount of prandial insulin should be
matched to carbohydrate intake, premeal blood glucose,
and anticipated physical activity.
10. Drug Therapy-
Type I
Diabetes
Mellitus
Question: When should a sensor-augmented low
glucose threshold suspend pump be considered for
patients?
Answer: A sensor-augmented low glucose
threshold suspend pump should be considered for
patients with frequent nocturnal hypoglycemia,
recurrent severe hypoglycemia, or hypoglycemia
unawareness.
Question: How can the use of automated insulin
delivery systems benefit adolescents with type 1
diabetes?
Answer: Automated insulin delivery systems in
adolescents with type 1 diabetes can improve
glycemic control and reduce the risk of
hypoglycemia.
11. Drug Therapy-
Type II
Diabetes
Mellitus
Question: When is insulin therapy recommended for adults with newly
diagnosed type 2 diabetes?
Answer: Insulin therapy (with or without additional agents) is
recommended for adults with newly diagnosed type 2 diabetes who are
symptomatic and/or have A1C of 10% (86 mmol/mol) or greater and/or
blood glucose levels of 300 mg/dL (16.7 mmol/L) or greater.
Question: When should a combination insulin therapy be considered?
Answer: Combination insulin therapy should be considered if blood
glucose levels are 300 to 350 mg/dL (16.7 to 19.4 mmol/L) or higher, or
if A1C is greater than 9% or 10% to 12% or higher. The regimen may be
simplified as glucose toxicity resolves.
Question: What are the recommended treatments for adults with an A1C of
7.5% or higher or 9% or higher?
Answer: Adults with an A1C of 7.5% or higher or 9% or higher should
be started on dual therapy with metformin (or another first-line agent)
plus another agent such as a GLP-1 receptor agonist, SGLT2 inhibitor,
DPP-4 inhibitor, thiazolidinedione, basal insulin, colsevelam,
bromocriptine QR, alpha-glucosidase inhibitor, sulfonylurea, or glinide.
Question: What should be done if metformin or alternative monotherapy
doesn't achieve or maintain the target A1C after 3 months?
Answer: If metformin or alternative monotherapy does not achieve or
maintain target A1C after 3 months, the addition of a GLP-1 receptor
agonist, SGLT2 inhibitor, DPP-4 inhibitor, thiazolidinedione, basal
insulin, Colsevelam, bromocriptine QR, AGI, sulfonylurea, or glinide is
recommended.
12. Drug Therapy-
Type II
Diabetes
Mellitus
Question: How is marked hyperglycemia defined in children or
adolescents with type 2 diabetes and what treatment is
recommended?
Answer: Marked hyperglycemia in children or adolescents with
type 2 diabetes is defined as an A1C of 8.5% or higher or a blood
glucose of 250 mg/dL (13.9 mmol/L) or higher. Basal insulin is
recommended while metformin is initiated and titrated to the
maximum tolerated dose.
Question: What are the potential side effects and risks associated
with insulin therapy for type 2 diabetes?
Answer: The potential side effects and risks include high risk of
hypoglycemia, weight gain, progression of diabetic kidney disease,
increased risk of hypoglycemia with lower estimated GFR, and
potential pulmonary toxicity with inhaled insulin. The
cardiovascular effects are generally neutral, as are the bone
effects and gastrointestinal symptoms.
Question: What happens if the target A1C is not achieved after 3
months of dual therapy?
Answer: If the target A1C is not achieved after 3 months of dual
therapy, triple therapy is recommended.
13. Drug Therapy-
Type II
Diabetes
Mellitus
added?
Answer: When basal insulin is added, noninsulin agents
may be continued, but sulfonylureas, DPP-4 inhibitors, and
GLP-1 receptor agonists are usually discontinued when
prandial insulin is added. If basal insulin has been titrated
to an acceptable fasting blood glucose level, but A1C is
above target or the insulin dose is greater than 0.5
units/kg/day, adding mealtime insulin or considering a GLP-
1 receptor agonist trial is recommended.
Question: What are the advantages of using insulin as a
treatment for type 2 diabetes?
Answer: Insulin increases glucose disposal, decreases
hepatic glucose production, suppresses ketogenesis, and
provides quicker metabolic control compared with
metformin. It has a high efficacy with a moderate to marked
lowering effect on both fasting plasma glucose and
postprandial glucose.
Question: What are the costs and disadvantages associated
with insulin treatment for type 2 diabetes?
Answer: The costs of insulin treatment are high and vary
based on the type, brand, and dosage. The disadvantages
include a high risk of hypoglycemia, potential weight gain,
