---
title: Type 2 Diabetes Management
description: A comprehensive clinical reference on the diagnosis, treatment, and monitoring of type 2 diabetes.
keywords: [type 2 diabetes, hyperglycemia, insulin resistance, metformin, GLP-1 agonists]
category: clinical
---

## Diagnostic Criteria and Screening

Type 2 diabetes is characterized by insulin resistance and relative insulin deficiency. Diagnostic criteria, as per the American Diabetes Association (ADA), include:

- Fasting plasma glucose ≥126 mg/dL (7.0 mmol/L), or
- 2-hour plasma glucose ≥200 mg/dL (11.1 mmol/L) during an oral glucose tolerance test, or
- Hemoglobin A1c ≥6.5% (48 mmol/mol), or
- Random plasma glucose ≥200 mg/dL (11.1 mmol/L) in a patient with classic symptoms of hyperglycemia.

Screening for type 2 diabetes is recommended for all adults aged 35-70 years who are overweight or obese (BMI ≥25 kg/m^2). Screening should be considered in younger individuals with additional risk factors, such as family history, physical inactivity, or high-risk race/ethnicity.

## Glycemic Management

The primary goal of type 2 diabetes management is to achieve and maintain optimal glycemic control, as measured by hemoglobin A1c. The ADA recommends an A1c target of <7.0% (53 mmol/mol) for most non-pregnant adults, with more or less stringent targets based on individual patient factors.

### Lifestyle Intervention
Comprehensive lifestyle modification, including medical nutrition therapy and regular physical activity, is the foundation of type 2 diabetes management. Patients should be counseled on a healthy, low-calorie, low-fat diet and encouraged to engage in at least 150 minutes per week of moderate-intensity exercise.

### Pharmacologic Therapy
If lifestyle intervention alone is insufficient to achieve glycemic targets, pharmacologic therapy is indicated. First-line medication is typically metformin, with a starting dose of 500-850 mg twice daily and titration to a maximum tolerated dose. If metformin is contraindicated or not tolerated, alternative first-line options include a glucagon-like peptide-1 (GLP-1) receptor agonist or a sodium-glucose cotransporter-2 (SGLT2) inhibitor.

For patients not at goal on metformin monotherapy, additional medications may be added in a stepwise fashion. Options include sulfonylureas, DPP-4 inhibitors, GLP-1 agonists, SGLT2 inhibitors, basal insulin, or a combination of these agents. The choice of additional therapy should be individualized based on patient factors, such as cardiovascular or renal comorbidities, risk of hypoglycemia, and cost considerations.

## Cardiovascular Risk Reduction

Individuals with type 2 diabetes are at increased risk of cardiovascular disease, and comprehensive management should include strategies to mitigate this risk.

### Blood Pressure Management
The American Heart Association (AHA) and American College of Cardiology (ACC) recommend a blood pressure target of <130/80 mmHg for most adults with diabetes. Pharmacologic therapy, typically with an angiotensin-converting enzyme (ACE) inhibitor or angiotensin II receptor blocker (ARB), should be initiated for patients with blood pressure ≥130/80 mmHg.

### Lipid Management
The AHA/ACC guidelines recommend statin therapy for all adults with diabetes aged 40-75 years, regardless of baseline lipid levels. For individuals with additional cardiovascular risk factors, more intensive statin therapy may be indicated.

### Antiplatelet Therapy
The use of low-dose aspirin (81-100 mg daily) for primary prevention of cardiovascular events is recommended for adults with diabetes aged 40-75 years who have a 10-year atherosclerotic cardiovascular disease (ASCVD) risk of ≥10%.

## Microvascular Complications Screening and Management

Individuals with type 2 diabetes are at risk of developing microvascular complications, including diabetic retinopathy, nephropathy, and neuropathy. Regular screening and appropriate management are essential.

### Diabetic Retinopathy
All patients with type 2 diabetes should undergo a comprehensive dilated eye examination by an ophthalmologist or optometrist at the time of diagnosis and annually thereafter. Treatment options for diabetic retinopathy include laser photocoagulation, intravitreal anti-VEGF injections, and vitrectomy, as per the recommendations of the American Academy of Ophthalmology.

### Diabetic Nephropathy
Screening for diabetic kidney disease should include annual measurement of urinary albumin-to-creatinine ratio and estimated glomerular filtration rate (eGFR). The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines recommend the use of ACE inhibitors or ARBs as first-line therapy for patients with diabetic kidney disease and albuminuria.

### Diabetic Neuropathy
Patients with type 2 diabetes should be screened for symptoms of neuropathy, including numbness, tingling, or pain in the extremities. Treatment options include tricyclic antidepressants, serotonin-norepinephrine reuptake inhibitors, calcium channel alpha-2-delta ligands, and topical lidocaine or capsaicin.

## Hypoglycemia Management

Hypoglycemia is a potentially serious adverse effect of diabetes medications, particularly insulin and sulfonylureas. Patients should be educated on the recognition and self-management of hypoglycemic episodes, including the use of glucose tablets or gel.

Severe hypoglycemia, defined as an event requiring assistance from another person for recovery, is a medical emergency. Glucagon, either injectable or nasal, should be prescribed for all patients at risk of severe hypoglycemia, and caregivers should be trained on its administration.

## Multidisciplinary Care and Ongoing Monitoring

Effective management of type 2 diabetes requires a multidisciplinary approach, with involvement of primary care providers, endocrinologists, dietitians, diabetes educators, and other specialists as needed. Patients should receive comprehensive education on self-care, including medication adherence, glucose monitoring, and lifestyle modifications.

Regular monitoring of glycemic control, cardiovascular risk factors, and microvascular complications is essential. The frequency of clinical visits and laboratory testing should be individualized based on the patient's clinical status and treatment regimen.

In summary, the comprehensive management of type 2 diabetes involves a combination of lifestyle intervention, pharmacologic therapy, cardiovascular risk reduction, screening and management of microvascular complications, and a multidisciplinary, patient-centered approach to care.