Diabetes has no cure. It is a chronic disease that requires life-long medical care paired with multifactorial strategies to reduce the risk of acute complications and serious long-term complications.1 Collaborating with patients to develop individualized management plans and glycemic targets and supporting their efforts to change behaviors are important components of improving outcomes.1

Lifestyle interventions include healthy eating, regular exercise, smoking cessation, weight management, and adopting strategies for coping with stress. Patients may need support with taking and managing medications; monitoring glucose levels and blood pressure; actively participating in screenings for eye, foot, and renal complications; adhering to the recommended immunization schedule; and identifying self-management problems in order to develop strategies to overcome them. The 2018 Standards of Care update now includes various settings and platforms (including a technology aspect) for effective diabetes self-management education. Furthermore, the update highlights the importance of individualizing eating plans as there is no “universal ideal macronutrient distribution,” though a low-carb diet should be maintained.1

Management plans should reflect the patient’s individual preferences, values, and goals, as well as his or her age, cognitive abilities, school/work schedule and conditions, health beliefs, support systems, eating patterns, physical activity, social situation, financial concerns, cultural factors, literacy and numeracy (mathematical literacy) skills, diabetes complications, comorbidities, health priorities, other medical conditions, preferences for care, and life expectancy. A comprehensive medical evaluation should be conducted at diagnosis.1


components-diabetes-evaluation-2 Reference 1.

Unless there are contraindications, pharmacological treatment for diabetes should begin with metformin at diagnosis. When metformin is contraindicated or if the patient cannot tolerate it, consideration should be given to a drug from another class, such as a sulfonylurea, thiazolidinedione, DPP-4 inhibitor, SLFT inhibitor, GLP-1 receptor agonist, or insulin.1

While treatment should always be individualized to best meet each patient’s needs,2 the following figure represents general recommendations for treatment selection, guided by A1c level and blood glucose levels.1


Reference 1.

Clinicians should consider initiating dual combination therapy in patients with AIC ≥9% (75 mmol/mol) even at diagnosis since this has been shown to help patients reach glycemic goals quicker. 1  Moreover, data from several studies and recent meta-analyses show earlier initiation of combination therapy has the potential to increase the number of patients achieving glycemic goals; newer agents may also reduce the risk of hypoglycemia and body weight gain.3 In patients with type 2 diabetes and established ASCVD (atherosclerotic cardiovascular disease), antihyperglycemic therapy should start with lifestyle management and metformin, and subsequently incorporate an agent proven to decrease major adverse cardiovascular events and cardiovascular mortality (i.e. liraglutide and empagliflozin) unless otherwise contraindicated.1

Complete guidelines for diabetes treatment can be found at:


  1. American Diabetes Association. Standards of Medical Care in Diabetes- 2018. Diabetes Care. 2018;41(suppl 1),
  2. Garber AJ et al. Consensus Statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the Comprehensive Type 2 Diabetes Management Algorithm – 2018 Executive Summary. Endocr Pract. 2018;24(No.1)
  3. Bianchi C, Daniele G, Dardano A, Miccoli R, Del Prato S. Early combination therapy   with oral glucose-lowering agents in type 2 diabetes. Drugs. 2017;77:247-264.

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