How will this condition be treated?

Initial Management: Lifestyle Modifications

The cornerstone of T2DM treatment is lifestyle modification. This includes:

• Dietary Management: A balanced diet emphasizing whole grains, fruits, vegetables, lean proteins, and healthy fats is crucial. Reducing intake of processed foods, sugary drinks, and saturated/trans fats is essential. The Dietary Approaches to Stop Hypertension (DASH) diet and the Mediterranean diet are often recommended.
• Regular Physical Activity: At least 150 minutes of moderate-intensity aerobic exercise per week, along with resistance training twice a week, is advised. Exercise improves insulin sensitivity and helps with weight management.
• Weight Management: Achieving and maintaining a healthy weight is vital. Even modest weight loss (5-10% of body weight) can significantly improve glycemic control.
• Smoking Cessation: Smoking exacerbates insulin resistance and increases cardiovascular risk.
• Education: Comprehensive diabetes self-management education is essential to empower patients to actively participate in their care.

Pharmacological Interventions

If lifestyle modifications are insufficient to achieve glycemic targets (HbA1c <7%), pharmacological interventions are initiated. The choice of medication depends on individual patient factors, including comorbidities, cost, and potential side effects.

First-Line Medications

• Metformin: A biguanide that reduces hepatic glucose production and improves insulin sensitivity. It is generally the first-line drug unless contraindicated (e.g., renal impairment).

Second-Line Medications (added to Metformin)

• Sulfonylureas: Stimulate insulin secretion from the pancreas. Examples include glimepiride and gliclazide. Risk of hypoglycemia is a concern.
• Thiazolidinediones (TZDs): Improve insulin sensitivity in muscle and adipose tissue. Examples include pioglitazone. Potential side effects include fluid retention and heart failure.
• DPP-4 Inhibitors: Prolong the action of incretin hormones, which stimulate insulin release and suppress glucagon secretion. Examples include sitagliptin and linagliptin.
• SGLT2 Inhibitors: Reduce glucose reabsorption in the kidneys, leading to increased glucose excretion in the urine. Examples include empagliflozin and dapagliflozin. Cardiovascular and renal benefits have been demonstrated.
• GLP-1 Receptor Agonists: Mimic the action of incretin hormones, promoting insulin secretion, suppressing glucagon, and slowing gastric emptying. Examples include liraglutide and semaglutide. Often associated with weight loss.

Advanced Therapies

For patients who do not achieve glycemic control with oral medications, insulin therapy may be necessary.

• Basal Insulin: Long-acting insulin analogs (e.g., glargine, detemir) provide a steady level of insulin throughout the day.
• Bolus Insulin: Rapid-acting insulin analogs (e.g., lispro, aspart) are used to cover meals.
• Insulin Combinations: Pre-mixed insulin formulations combine basal and bolus insulin.

Monitoring and Complications Management

Regular monitoring is crucial to assess treatment effectiveness and prevent complications.

• HbA1c: Measures average blood glucose levels over the past 2-3 months. Target HbA1c is typically <7%.
• Self-Monitoring of Blood Glucose (SMBG): Patients monitor their blood glucose levels at home to adjust medication and lifestyle.
• Annual Screening: Regular screening for microvascular complications (retinopathy, nephropathy, neuropathy) and macrovascular complications (cardiovascular disease, peripheral artery disease) is essential.

Management of complications involves specific interventions tailored to the affected organ system. For example, ACE inhibitors or ARBs are used to protect kidney function in diabetic nephropathy.

Medication Class	Mechanism of Action	Common Side Effects
Metformin	Reduces hepatic glucose production, improves insulin sensitivity	Gastrointestinal upset (nausea, diarrhea)
Sulfonylureas	Stimulates insulin secretion	Hypoglycemia, weight gain
SGLT2 Inhibitors	Reduces glucose reabsorption in kidneys	Genital mycotic infections, urinary tract infections