The 2022 American Diabetes Association (ADA) Standards of Medical Care indicate that since the hallmark of type 1 diabetes mellitus (T1DM) is absent or near-absent beta-cell function, insulin treatment is essential for individuals with T1DM.

ADA-Recommended Pharmacologic Therapy for Adults With T1DM includes the following:

• Most patients with T1DM should be treated with multiple daily injections of prandial and basal insulin or continuous SC insulin infusion.
• Most patients with T1DM should utilize rapid-acting insulin analogues to lessen hypoglycemia risk.
• Patients with T1DM should receive education on how to match mealtime insulin doses to carbohydrate intake, fat and protein content, and anticipated physical activity.

ADA-Recommended Pharmacologic Therapy for Type 2 Diabetes Mellitus (T2DM) includes the following:

• First-line therapy depends on comorbidities, patient-centered treatment factors, and management needs and generally includes metformin and comprehensive lifestyle modification.
• Other medications (glucagon-like peptide-1 receptor agonists [GLP-1s], sodium-glucose cotransporter-2 inhibitors [SGLT2s]), with or without metformin based on glycemic needs, are appropriate initial therapy for patients with T2DM or those who are at high risk for atherosclerotic cardiovascular disease, heart failure, and/or chronic kidney disease.
• Metformin should be continued upon initiation of insulin therapy (unless contraindicated or not tolerated) for ongoing glycemic and metabolic benefits.
• Early combination therapy may be considered in some patients at treatment initiation to extend the time to treatment failure.
• The early introduction of insulin should be considered if there is evidence of ongoing catabolism (weight loss), if symptoms of hyperglycemia are present, or when A1C levels (>10% [86 mmol/mol]) or blood glucose levels (≥300 mg/dL [16.7 mmol/L]) are very high.
• A patient-centered approach should guide clinicians in the selection of pharmacologic agents. Prescribers should also consider the effects on cardiovascular and renal comorbidities, efficacy, hypoglycemia risk, impact on weight, cost and access, risk of side effects, and patient preferences.
• Among patients with T2DM who have established atherosclerotic cardiovascular disease or indicators of high cardiovascular risk, established kidney disease, or heart failure, a SGLT2 inhibitor and/or GLP-1 receptor agonist with demonstrated cardiovascular disease benefit is recommended as part of the glucose-lowering regimen and comprehensive cardiovascular risk reduction, independent of A1C and in consideration of patient-specific factors.
• In patients with T2DM, a GLP-1 receptor agonist is preferred to insulin when possible.
• If insulin is utilized, combination therapy with a GLP-1 receptor agonist is recommended for greater efficacy and durability of treatment effect.
• Recommendations for treatment intensification in patients not meeting treatment goals should not be postponed.
• Medication-regimen and medication-taking behavior should be reevaluated at regular intervals (every 3-6 months) and modified as necessary to integrate specific factors that impact choice of treatment.
• Clinicians should be aware of the potential for overbasalization with insulin therapy. Clinical signals that may prompt evaluation of overbasalization include basal dose more than an estimated 0.5 IU/kg/day, high bedtime-morning or postpreprandial glucose differential, hypoglycemia (aware or unaware), and high glycemic variability. Indication of overbasalization should encourage reevaluation to further individualize therapy.

News and Clinical Data

The CDC 2021 National Health Interview evaluated whether insulin users skipped doses, took less than needed, or delayed buying insulin, suggesting that an estimated 16.5% of users ( approximately 1.3 million individuals) rationed insulin in the past year. Factors associated with increased rationing of insulin included insurance coverage, socioeconomic/employment status, and younger age.

According to a study recently published in Annals of Internal Medicine, use of SGLT2 inhibitors and GLP-1 receptor agonists as first-line treatment for T2DM would improve outcomes, but the drugs’ cost would need to decrease by at least 70% to make these agents cost-effective. Key findings revealed that use of these drug classes was associated with lower lifetime rates of congestive heart failure, ischemic heart disease, myocardial infarction, and stroke compared with metformin.  

Findings published in JAMA Network Open revealed that among 150 adults, use of a low-carbohydrate diet significantly decreased A1C by 0.23% compared with the regular diet over 6 months. The authors concluded that their findings suggest that a low-carbohydrate diet, if sustained, might be a valuable dietary approach for preventing and treating T2DM, but they added that more research is warranted.

The content contained in this article is for informational purposes only. The content is not intended to be a substitute for professional advice. Reliance on any information provided in this article is solely at your own risk.

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