How will this condition be treated?

Initial Assessment and Diagnosis

Diagnosis of T2DM is typically based on one of the following criteria:

• Fasting plasma glucose ≥ 126 mg/dL (7.0 mmol/L)
• 2-hour plasma glucose ≥ 200 mg/dL (11.1 mmol/L) during an oral glucose tolerance test (OGTT)
• HbA1c ≥ 6.5%
• Random plasma glucose ≥ 200 mg/dL (11.1 mmol/L) in a patient with classic symptoms of hyperglycemia (polyuria, polydipsia, unexplained weight loss)

Initial assessment also includes a comprehensive medical history, physical examination (including foot examination), and laboratory investigations to assess renal function, lipid profile, and liver function.

Lifestyle Modifications

Lifestyle interventions form the cornerstone of T2DM management. These include:

• Dietary Changes: A balanced diet emphasizing whole grains, fruits, vegetables, lean protein, and healthy fats. Reducing intake of processed foods, sugary drinks, and saturated/trans fats is crucial. Medical Nutrition Therapy (MNT) guided by a registered dietitian is highly recommended.
• Physical Activity: At least 150 minutes of moderate-intensity aerobic exercise per week, spread over at least 3 days, with no more than 2 consecutive days without exercise. Resistance training should also be incorporated at least twice a week.
• Weight Management: Achieving and maintaining a healthy weight through diet and exercise. Even modest weight loss (5-10%) can significantly improve glycemic control.
• Smoking Cessation: Smoking exacerbates insulin resistance and increases cardiovascular risk.

Pharmacological Interventions

If lifestyle modifications are insufficient to achieve glycemic targets, pharmacological therapy is initiated. The choice of medication depends on individual patient factors, including HbA1c level, comorbidities, and risk of hypoglycemia.

First-Line Medications

• Metformin: Generally the first-line drug, it reduces hepatic glucose production and improves insulin sensitivity. Contraindicated in patients with significant renal impairment.

Second-Line Medications (added to Metformin)

• Sulfonylureas: Stimulate insulin secretion. Risk of hypoglycemia and weight gain.
• Thiazolidinediones (TZDs): Improve insulin sensitivity. Associated with fluid retention and increased risk of heart failure.
• DPP-4 Inhibitors: Enhance incretin hormone activity, leading to increased insulin secretion and decreased glucagon secretion. Generally well-tolerated.
• SGLT2 Inhibitors: Reduce glucose reabsorption in the kidneys, leading to increased urinary glucose excretion. Cardiovascular and renal benefits have been demonstrated.
• GLP-1 Receptor Agonists: Enhance incretin hormone activity, promoting insulin secretion, suppressing glucagon secretion, and slowing gastric emptying. Often associated with weight loss.

Insulin Therapy

Insulin may be required if glycemic control cannot be achieved with oral medications. Different types of insulin are available (basal, bolus, premixed) and the regimen is tailored to the individual patient’s needs.

Monitoring and Follow-Up

Regular monitoring is essential to assess treatment effectiveness and adjust therapy as needed. This includes:

• HbA1c: Measured every 3-6 months to assess long-term glycemic control.
• Self-Monitoring of Blood Glucose (SMBG): Frequency depends on the treatment regimen and individual patient needs.
• Annual Screening: For microvascular complications (retinopathy, nephropathy, neuropathy) and macrovascular complications (cardiovascular disease, peripheral artery disease).
• Regular Lipid Profile and Renal Function Tests.

Special Considerations

Treatment strategies need to be individualized based on the presence of comorbidities such as hypertension, dyslipidemia, and cardiovascular disease. Patients with chronic kidney disease require careful monitoring and dose adjustments of medications.