Patient with newly diagnosed type 2 diabetes? Remember these steps
In addition to promoting glycemic control, you’ll need to initiate statin therapy for CV risk, administer appropriate vaccinations, and screen for depression regularly.
PRACTICE RECOMMENDATIONS
› Individualize lifestyle modifications, considering personal and cultural experiences, health literacy, access to healthy foods, willingness and ability to make behavior changes, and barriers to change. C
› Initiate medication therapy at diagnosis, considering medication efficacy and cost, hypoglycemia risk, weight effects, benefits in cardiovascular and kidney disease, and patient-specific comorbidities. C
› Start basal insulin as first-line therapy in patients with severe baseline hyperglycemia, symptoms of hyperglycemia, or evidence of catabolism. C
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Because of their longitudinal relationships with patients, family physicians are in an optimal position to assess a patient’s physical capacity level and provide individualized counseling. Several systematic reviews have demonstrated that counseling on exercise increases patients’ participation in physical activity.29 Encourage your patients with T2D to exercise regularly, considering each individual’s ability to engage in physical activity.
Weight loss
Include weight management in the initial treatment of patients with newly diagnosed T2D. Weight loss decreases hepatic glucose production and increases peripheral insulin sensitivity and insulin secretion.30 Moderate decreases in weight (5%-10%) can reduce complications related to diabetes, and sustained significant weight loss (> 10%) can potentially cause T2D remission (A1C < 6.5% after stopping diabetes medications).31,32
Diabetes self-management education supports patients by giving them tools for making and maintaining lifestyle changes. Understanding individual barriers to change and addressing these during motivational interviews is important. Through a qualitative interview study, participants in a diabetes self-management program revealed 4 factors that motivated them to maintain lifestyle changes: support from others, experiencing the impact of the changes they made, fear of T2D complications, and forming new habits.33 Family physicians are key in helping patients acquire knowledge and support to make the lifestyle modifications needed to manage newly diagnosed T2D.
Individualized pharmacotherapy considerations
For decades, the initial pharmacotherapeutic regimen for patients with newly diagnosed T2D considered the patient’s baseline A1C as a major driver for therapy. Metformin has been the mainstay in T2D treatment due to its clinical efficacy, minimal risk for hypoglycemia, and low cost. Regardless of the regimen, pharmacotherapy should be initiated at the time of T2D diagnosis in conjunction with the aforementioned lifestyle modifications.34
When selecting pharmacotherapy, practice guidelines recommend considering the efficacy and adverse effects of medications, patient-specific comorbidities, adherence, cost, and a patient’s lifestyle factors.34 Drug classes with pertinent information are listed in TABLE 2.34-54 After starting medication, monitor the A1C level every 3 months to determine whether therapy should be intensified. Patients should have their labs drawn ahead of the quarterly visit, or point-of-care measurements may be used to facilitate in-person patient–provider discussions.
Continue to: Consider patient-specific factors when starting pharmacotherapy
