Type 2 diabetes is more a broad spectrum of symptoms and comorbidities than it is a single disease, and approaches to managing type 2 diabetes are as heterogeneous and as nuanced as the patients themselves.

“Good diabetes care is always nuanced because it is individualized,” said Kristina Utzschneider, MD, Physician at the VA Puget Sound, Director of the VA Diabetes Care Program, and Assistant Professor of Metabolism, Endocrinology, and Nutrition at the University of Washington. “Some of our patients with obesity are super insulin resistant and our care ends up being very different, as some people respond very quickly to certain medications or lifestyle interventions. Care has to be individualized.”

Dr. Utzschneider will open a symposium, When the Treatment of Type 2 Diabetes Becomes Nuanced, on Sunday, June 22, from 8:00–9:30 a.m., in Room W185 A–D of the McCormick Place Convention Center. On-demand access to recorded presentations will be available to registered participants following the conclusion of the 85^th Scientific Sessions, from June 25–August 25.

“Good diabetes care is always nuanced because it is individualized.”

— Kristina Utzschneider, MD

Patient weight is one of the variations clinicians must consider. Clinicians may expect to see obesity in type 2 diabetes, but some patients are lean.

“People can be lean and still have lots of intrabdominal fat and be insulin resistant,” Dr. Utzschneider pointed out. “However, it is important to consider other diagnoses in a lean patient with diabetes. I occasionally diagnose a patient who has been treated as type 2 but is actually type 1 and was on the wrong treatment.”

Diabetes-related ketoacidosis (DKA) is another common surprise in type 2 diabetes and in patients who are not insulin dependent.

“That can make a big difference in how you treat the patient, especially if you can use an oral medication or a non-insulin agent,” said Priya Vellanki, MD, MS, Associate Professor of Endocrinology and Medical Director of the Grady Endocrinology Clinic at Emory University. “This presentation of type 2 diabetes is under recognized or even misdiagnosed as type 1 diabetes.”

Glucagon-like peptide-1 (GLP-1) agents may be appropriate for patients with comorbidities such as obesity, hypertension, and dyslipidemia, she added. There may also be indications for sodium-glucose cotransporter-2 (SGLT2) inhibitors.

End-stage liver disease is emerging as a more common complication as more patients live longer with type 2 diabetes, noted Thomas Jensen, MD, Associate Professor of Endocrinology, Director of Diabetes and Metabolic Medicine for Transplant, and Co-Director of the MASLD Multidisciplinary Clincs at the University of Colorado School of Medicine.

The same metabolic syndrome seen in type 2 diabetes is becoming the leading cause of fatty liver disease in the general population. Individuals with end-stage liver disease may have false low readings on A1C tests and may benefit from continuous glucose monitoring (CGM) or frequent finger sticks.

“It is important to work as a team with the gastroenterologist or hepatologist in helping to manage a patient,” Dr. Jensen said. “Recognize that complications in liver disease may make it difficult for diabetes management.”

Individuals with hepatic encephalopathy may have changing cognition that can complicate diabetes medication regimens with missed doses. There are also liver cancer concerns. Metformin or GLP-1 agents may reduce the risk of hepatocellular carcinoma in patients with decompensated cirrhosis as well as benefit diabetes.

A growing number of patients with diabetes-related kidney disease are living long enough to develop end-stage renal disease. The same drugs may benefit both their diabetes and kidney disease.

“There are number of new medications, such as the SGLT2 inhibitors and GLP-1 receptor agonists, that were developed for managing hyperglycemia but that also reduce cardiovascular morbidity and mortality,” said Jeffrey S. Berns, MD, Professor of Medicine and Pediatrics at the University of Pennsylvania.

 “We’ve also found, in addition to cardiovascular benefit, that loss of kidney function slows in people with both diabetes and chronic kidney disease,” he continued. “These agents have become standard of care for many people with kidney disease regardless of whether or not they have diabetes. The care of diabetes is nuanced, and it’s changing as new medications become available.”