The 2023 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 analogs 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.

2023 ADA Recommended Pharmacologic Therapy for Type 2 Diabetes Mellitus (T2DM) includes the following:

  • Patient-centered treatment factors, including comorbidities and treatment goals, should guide pharmacologic therapy.
  • Healthy lifestyle behaviors, diabetes self-management education and support, avoidance of clinical inertia, and social determinants of health should be considered in the glucose-lowering management of T2DM.
  • In adults with T2DM and established/high risk of atherosclerotic cardiovascular disease, heart failure, and/or chronic kidney disease, the treatment regimen should include agents that reduce cardiorenal risk.
  • Pharmacologic approaches that provide adequate efficacy to achieve and maintain treatment goals should be considered, such as metformin or other agents, including combination therapy.
  • Weight management is an impactful component of glucose-lowering management in T2DM. The glucose-lowering treatment regimen should consider approaches that support weight management goals.
  • Metformin should be continued upon initiating insulin therapy (unless contraindicated or not tolerated) for ongoing glycemic and metabolic benefits.
  • Early combination therapy can be considered in some individuals 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 the choice of pharmacologic agents. Consider the effects on cardiovascular and renal comorbidities, efficacy, hypoglycemia risk, impact on weight, cost and access, risk for adverse effects, and individual preferences.
  • Among individuals with T2DM who have established atherosclerotic cardiovascular disease or indicators of high cardiovascular risk, established kidney disease, or heart failure, a sodium-glucose cotransporter-2 inhibitor and/or glucagon-like peptide 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 person-specific factors.
  • In adults with T2DM, a glucagon-like peptide 1 receptor agonist is preferred to insulin when possible.
  • If insulin is employed, combination therapy with a glucagon-like peptide 1 receptor agonist is recommended for greater efficacy, durability of treatment effect, and weight and hypoglycemia benefit.
  • Recommendation for treatment intensification for individuals not meeting treatment goals should not be delayed.
  • Medication regimen and medication adherence should be reevaluated at regular intervals (every 3–6 months) and adjusted as needed to incorporate specific factors that impact treatment choice.
  • Clinicians should be aware of the potential for over-basalization with insulin therapy. Clinical signals that may prompt evaluation of over-basalization include basal dose more than approximately 0.5 units/kg/day, high bedtime–morning or postprandial glucose differential, hypoglycemia (aware or unaware), and high glycemic variability. Indication of over-basalization should prompt reevaluation to individualize therapy further.

News and Clinical Data

On November 3, 2023, the FDA issued a press release advising patients not to use a nonprescription product currently being sold as Dr. Ergin’s Sugar MD Advanced Glucose Support for blood glucose management due to risks for adverse events. The FDA stated that it conducted a laboratory analysis of the product and confirmed it contains the prescription drugs glyburide and metformin. The FDA noted that individuals who use the product could take a larger combined dose of the diabetes drugs than they intend, which could lead to adverse events. The risk for adverse events is highest for patients with chronic kidney disease. More information can be found on the FDA website.

In a systematic literature review published in Nutrients, researchers reviewed data from human clinical trials to investigate the impact of probiotics on promoting a healthy gut microbiome and its role in patients with T2DM. The authors discovered that patients with T2DM taking metformin demonstrated enhanced glycemic control via the coadministration of probiotics; however, more studies are warranted to understand the effect of different microbial strains and the ideal dosage of probiotics to enhance outcomes in patients with T2DM.

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.