Treatment Algorithm

Introduction

The primary treatment goals of managing type 2 diabetes (T2D) are to:

• Eliminate symptoms of hyperglycemia
• Recognize the symptoms of hypoglycemia
• Achieve and maintain normal or near-normal metabolic and biochemical parameters (both fasting and postprandial blood glucose levels, A1C [Table 20-1] and time in range [70 to 180 mg/dL], low-density lipoprotein (LDL) and high-density lipoprotein (HDL) cholesterol, and fasting triglycerides)
• Achieve normal blood pressure and address procoagulant state
• Reduce insulin resistance and its adverse metabolic consequences
• Assist the patient in achieving and maintaining a reasonable body weight
• Prevent or delay the development and progression of microvascular and macrovascular complications

Therapeutic efforts to achieve these goals involve using a variety of treatment modalities:

• Dietary modifications
• Regular physical activity
• Aspirin therapy (if indicated)
• Antidiabetic agents
• Insulin (via injections, inhalation, or pump)

An individualized approach is recommended based on the following:

• Patient age
• The presence of coexisting illnesses and/or diabetes-related complications
• Lifestyle, including:
• -Attitude
• -Habits
• -Cultural/ethnic status
• Financial considerations
• Ability to learn and follow self-management skills
• Level of patient motivation.

The cornerstone of effective diabetes management is maintaining good glycemic control. Compelling evidence indicates that long-term glycemic control can prevent or delay the microvascular complications of diabetes. The Diabetes Control and Complications Trial (DCCT) and the United Kingdom Prospective Diabetes Study (UKPDS) demonstrated definitively the value of improved glycemic therapy in patients with type 1 diabetes (T1D) and type 2 diabetes in delaying the onset and slowing the progression of retinopathy, nephropathy, and neuropathy. The benefits of reducing glycemia are seen in both type 1 and type 2 diabetes.

The American Diabetes Association (ADA) now recommends establishing a management goal of achieving the best possible blood glucose control in patients with type 2 diabetes. Treatment methods for managing type 2 diabetes should focus on:

• Dietary modifications
• Exercise
• Weight control
• Supplemental oral hypoglycemic agents and/or insulin as needed.

The 2024 ADA Standards of Medical Care in Diabetes include an algorithm (Figure 20-1) that provides a general guideline for making decisions regarding the various types of pharmacologic therapy. In the wake of the unexpected success of cardiovascular (CV) outcome trials of several sodium glucose cotransporter type 2 (SGLT2) inhibitors and glucogonlike peptide 1 (GLP-1) receptor agonists, the approach to pharmacologic treatment of T2D has undergone a paradigm shift to prioritize agents that offer benefits beyond glycemic control. This is reflected in the algorithm, which now prominently includes recommendations for patients with or at risk of atherosclerotic cardiovascular disease (ASCVD), heart failure (HF), and chronic kidney disease (CKD), independent of their baseline glycosylated hemoglobin (A1C), A1C target, or metformin use. Another significant change is a shift away from metformin as the default first-line pharmacological therapy (in conjunction with lifestyle changes) to include other options depending on patient-centered factors, including comorbidities and patient-specific glycemic management needs. Additionally, the algorithm now recognizes that sequential addition of therapy need not be the only approach to treatment intensification; switching therapies or weaning current therapy are presented as alternatives means of therapeutic tailoring. Finally, the algorithm emphasizes three important factors in agent selection: 1) minimization of the risk of hypoglycemia; 2) minimization of weight gain/promotion of weight loss; and 3) affordability and access concerns (use of generics where available).

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