## Initial Management of Newly Diagnosed Type 2 Diabetes **Key Point:** The first step in newly diagnosed type 2 diabetes is **baseline assessment for complications and comorbidities**, followed by **metformin monotherapy + lifestyle intervention**. Dual therapy or insulin is reserved for inadequate glycaemic control after 3 months of monotherapy. ### Baseline Investigations in Newly Diagnosed Diabetes | Investigation | Purpose | Rationale | | --- | --- | --- | | Lipid profile (TC, LDL, HDL, TG) | Assess cardiovascular risk | 80% of T2DM deaths are CV-related | | Urine albumin-to-creatinine ratio (UACR) or 24-h urine protein | Screen for diabetic nephropathy | Early detection enables intervention | | Serum creatinine / eGFR | Assess renal function | Baseline before metformin; guides dosing | | ECG | Screen for silent ischemia | Asymptomatic CAD common in diabetes | | Dilated retinal examination | Screen for diabetic retinopathy | Prevents blindness if detected early | | Foot examination | Screen for neuropathy and ulcer risk | Prevents amputation | **High-Yield:** This patient has **no evidence of complications** on history/exam, but baseline investigations are MANDATORY to: 1. Detect silent complications (nephropathy, neuropathy, CAD) 2. Establish baseline for monitoring progression 3. Guide intensity of glycaemic control targets 4. Identify need for additional medications (statins, ACE-I/ARB) ### First-Line Pharmacotherapy: Metformin Monotherapy **Indications:** - First-line agent for all newly diagnosed type 2 diabetes - Reduces HbA1c by 1–2% - Weight-neutral or weight-reducing - Cardioprotective and reduces mortality - No hypoglycaemia risk **Contraindications to check:** - eGFR <30 mL/min/1.73m² (absolute) - eGFR 30–45: use with caution, reduce dose - Acute illness, sepsis, dehydration, contrast dye (hold temporarily) **Dose:** Start 500 mg daily or BD; titrate to 1500–2000 mg/day in divided doses ### Intensive Lifestyle Modification (Equally Important) 1. **Weight loss:** 5–10% reduction improves insulin sensitivity 2. **Physical activity:** ≥150 min/week moderate-intensity aerobic + resistance training 3. **Dietary intervention:** - Reduce refined carbohydrates and added sugars - Increase fiber (whole grains, vegetables, legumes) - Reduce saturated fat - Portion control 4. **Smoking cessation** if applicable **Clinical Pearl:** Intensive lifestyle intervention alone can reduce HbA1c by 1–2% and may delay or prevent need for pharmacotherapy progression. This patient is an ideal candidate given early diagnosis and modifiable risk factors. ### When to Escalate Therapy - **After 3 months:** If HbA1c remains >7% on metformin monotherapy + lifestyle, add second agent (GLP-1 RA, SGLT2i, DPP-4i, or sulfonylurea depending on CV/renal risk) - **Insulin:** Reserved for HbA1c >9–10% despite dual/triple therapy or if acute decompensation ```mermaid flowchart TD A[Newly Diagnosed T2DM]:::outcome --> B[Baseline investigations<br/>Lipids, UACR, eGFR, ECG]:::action B --> C{eGFR adequate<br/>for metformin?}:::decision C -->|Yes| D[Start metformin 500 mg daily]:::action C -->|No| E[Adjust dose or choose<br/>alternative agent]:::action D --> F[Intensive lifestyle counselling<br/>Diet, exercise, weight loss]:::action F --> G[Recheck HbA1c at 3 months]:::action G --> H{HbA1c at goal?}:::decision H -->|Yes| I[Continue metformin +<br/>lifestyle, monitor 3-6 monthly]:::action H -->|No| J[Add second agent<br/>GLP-1 RA, SGLT2i, DPP-4i]:::action ``` **Mnemonic:** **ABCDE of T2DM Management** - **A**ssess baseline (investigations) - **B**lood glucose targets (individualized) - **C**omplications screening - **D**rug therapy (metformin first) - **E**ducation and lifestyle [cite:Park 26e Ch 8; Harrison 21e Ch 417]
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