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D i a b e t e s t r e a t m e n t a l g o r i t h m s
Glycemic Control Algorithm For
Type 2 Diabetes Mellitus In Adults
Glycemic Goals1
Initial Intervention2
Individualize goal based on
1. diabetes self-Management education and Recommended Options for Dual Therapy4
patient risk factors
2. self-monitored blood Glucose3 and 3. Medical nutrition3, Weight control3, exercise3 and 4. Monotherapy if A1c <1% above goal otherwise dual Recommended Options for Triple Therapy
Metformin
+ tZd or su5
+ Glp-1 or dpp-4 or AGi or colesevelam
Goals not met after 3 months of optimized therapy
If A1c < 1% above goal:
+ tZd or dpp-4 or AGi or su5 or colesevelam u if on monotherapy → add second agent (oral or Glp-1) u if on dual therapy → add third agent (oral or Glp-1 or insulin6) If A1c ≥ 1% above goal:
u if on monotherapy → add second agent +/- once-daily insulin6 or add two non-insulin agents (oral or Glp-1) Abbreviations
AGi
u if on dual therapy → add third agent (oral or Glp-1) Goals Achieved
pp postprandialsu sulfonylureatZd thiazolidinedione Goals not met after 3 Months of optimized therapy
consider referral to endocrinologist / diabetes specialist Footnotes
1 Intensify management if: Absent/stable cardiovascular disease, mild-moderate microvascular
3 these interventions should be maintained life-long; (refer to Medical nutrition, Weight loss, and exercise complications, intact hypoglycemia awareness, infrequent hypoglycemic episodes, recently diagnosed diabetes. Less intensive management if: evidence of advanced or poorly control ed cardiovascular
4 refer to the diabetes Medications supplement: Working together to Manage diabetes found in the texas and/or microvascular complications, hypoglycemia unawareness, vulnerable patient (ie, impaired diabetes council’s diabetes toolkit.
cognition, dementia, fall history). refer to tdc “A1c Goal” treatment strategy for further explanation. A1c is referenced to a non-diabetic range of 4-6% using a dcct-based assay. AdA clinical practice 5 if a su is selected, low dose glipizide er or glimepiride are recommended because they have a lower recommendations. Diabetes Care 2010;33(suppl 1):s19-20.
incidence of hypoglycemia than glyburide.
2 if initial A1c on presentation is ≥10%, consider the use of insulin, with or without oral agents, as the initial 6 refer to insulin Algorithm for type 2 diabetes Mel itus in children and Adults / initial insulin therapy for intervention (see insulin Algorithm). other agents may be introduced as glycemic control improves. if ketoacidosis or recent rapid weight loss, consider type 1 diagnosis.
diabetes Mel itus in children and Adults: A simplified Approach 1 of 3 – Glycemic control Algorithm for type 2 diabetes Mellitus nn Adults – revised 07-22-10
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D i a b e t e s t r e a t m e n t a l g o r i t h m s g lyC e m i C C o ntr o l b i b li o g r a P h y
Recent Review Articles
Repaglinide + Metformin
Inzucchi SE. Oral antihyperglycemic therapy for type 2 diabetes: scientific review. Moses R, Slobodniuk R, Boyages S, et al. Effect of repaglinide addition to metformin monotherapy on glycemic control in patients with type 2 diabetes. Diabetes Care. Inzucchi SE, McGuire DK. New drugs for the treatment of diabetes: part II: Incretin- based therapy and beyond. Circulation. 2008 Jan 29;117(4):574-84.
Nateglinide + Metformin
Horton ES, Clinkingbeard C, Gatlin M, et al. Nateglinide alone and in combination Riddle, MC. Glycemic management of type 2 diabetes: An emerging strategy with oral with metformin improves glycemic control by reducing mealtime glucose levels in type 2 agents, insulins and combinations. Endocrinol Metab Clin N Am. 2005;34(1):77-98.
diabetes. Diabetes Care. 2000;23(11):1660-5.
Drucker DJ, Sherman SI, Gorelick FS, Bergenstal RM, Sherwin RS, Buse JB. Incretin- Nateglinide + Thiazolidinedione
based therapies for the treatment of type 2 diabetes: evaluation of the risks and benefits. Rosenstock J, Shen SG, Gatlin MR, et al. Combination therapy with nateglinide Diabetes Care. 2010 Feb;33(2):428-33.
and a thiazolidinedione improves glycemic control in type 2 diabetes. Diabetes Care. Dual Therapy
Fonseca V, Grunberger G, Gupta S, et al. Addition of nateglinide to rosiglitazone Metformin or Sulfonylurea + Acarbose
monotherapy suppresses mealtime hyperglycemia and improves overall glycemic control. Chiasson JL, Josse RG, Hunt JA, et al. The efficacy of acarbose in the treatment of Diabetes Care. 2003;26(6):1685-90.
patients with non-insulin-dependent diabetes mellitus. A multicenter controlled clinical trial. Ann Intern Med. 1994;121(12):928-35.
Repaglinide + Thiazolidinedione
Raskin P, Jovanovic L, Berger S, et al. Repaglinide/troglitazone combination therapy: Metformin + Pioglitazone
improved glycemic control in type 2 diabetes. Diabetes Care. 2000;23(7):979-83.
Einhorn D, Rendell M, Rosenzweig J, et al. Pioglitazone hydrochloride in combination with metformin in the treatment of type 2 diabetes mellitus: a randomized, placebo- Liraglutide + Metformin
controlled study. The Pioglitazone 027 Study Group. Clin Ther. 2000;22(12):1395-409. Nauck M, Frid A, Hermansen K, Shah NS, Tankova T, Mitha IH, Zdravkovic M, Düring M, Matthews DR; LEAD-2 Study Group.Efficacy and safety comparison of Metformin + Rosiglitazone
liraglutide, glimepiride, and placebo, all in combination with metformin, in type 2 Fonseca V, Rosenstock J, Patwardhan R, et al. Effect of metformin and rosiglitazone diabetes: the LEAD (liraglutide effect and action in diabetes)-2 study. Diabetes Care. combination therapy in patients with type 2 diabetes mellitus: a randomized controlled trial. JAMA. 2000;283(13):1695-702. Erratum in: JAMA 2000;284(11):1384. Liraglutide + Sulfonylurea
Sulfonylurea + Pioglitazone
Marre M, Shaw J, Brändle M, Bebakar WM, Kamaruddin NA, Strand J, Zdravkovic Kipnes MS, Krosnick A, Rendell MS, et al. Pioglitazone hydrochloride in combination M, Le Thi TD, Colagiuri S; LEAD-1 SU study group. Liraglutide, a once-daily human with sulfonylurea therapy improves glycemic control in patients with type 2 diabetes GLP-1 analogue, added to a sulphonylurea over 26 weeks produces greater improvements mellitus: a randomized, placebo-controlled study. Am J Med. 2001;111(1):10-7.
in glycaemic and weight control compared with adding rosiglitazone or placebo in Sulfonylurea + Rosiglitazone
subjects with type 2 diabetes (LEAD-1 SU). Diabet Med. 2009 Mar;26(3):268-78.
Wolffenbuttel BH, Gomis R, Squatrito S, et al. Addition of low-dose rosiglitazone to sulphonylurea therapy improves glycaemic control in type 2 diabetic patients. Diabet Triple Therapy
Sulfonylurea + Metformin + Alpha glucosidase inhibitors
Metformin or Sulfonylurea + Exenatide
Lam KS, Tiu SC, Tsang MW, et al. Acarbose in NIDDM patients with poor control Buse JB, Henry RR, Han J, et.al. Effects of exenatide (exendin-4) on glycemic control on conventional oral agents. A 24-week placebo-controlled study. Diabetes Care. over 30 weeks in sulfonylurea-treated patients with type 2 diabetes. Diabetes Care. Standl E, Schernthaner G, Rybka J, et al. Improved glycaemic control with miglitol in DeFronzo RA, Ratner RE, Han J, et.al. Effects of exenatide (exendin-4) on glycemic inadequately-controlled type 2 diabetics. Diabetes Res Clin Pract. 2001;51(3):205-13.
control and weight over 30 weeks in metformin-treated patients with type 2 diabetes. Sulfonylurea + Metformin + Thiazolidinedione
Diabetes Care. 2005;28(5):1092-100.
Dailey GE 3rd, Noor MA, Park JS, et al. Glycemic control with glyburide/metformin Nateglinide or Repaglinide + Metformin
tablets in combination with rosiglitazone in patients with type 2 diabetes: a randomized, Raskin P, Klaff L, McGill J, et al. Efficacy and safety of combination therapy: repaglinide plus metformin versus nateglinide plus metformin. Diabetes Care. 2003;26(7):2063-8. Erratum in: Diabetes Care. 2003;26(9):2708. 2 of 3 – Glycemic control Algorithm for type 2 diabetes Mellitus nn Adults – revised 07-22-10
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D i a b e t e s t r e a t m e n t a l g o r i t h m s g lyC e m i C C o ntr o l b i b li o g r a P h y ( C o nt.)
Aljabri K, Kozak SE, Thompson DM. Addition of pioglitazone or bedtime insulin to maximal doses of sulfonylurea and metformin in type 2 diabetes patients with poor glucose control: a prospective, randomized trial. Am J Med. 2004;116(4):230-5.
Sulfonylurea + Metformin + Exenatide
Kendall DM, Riddle MC, Rosenstock J, et.al. Effects of exenatide (exendin-4) on glycemic control over 30 weeks in patients with type 2 diabetes treated with metformin and a sulfonylurea. Diabetes Care. 2005;28(5):1083-91.
Heine RJ, Van Gaal LF, Johns D, et al. Exenatide versus insulin glargine in patients with suboptimally controlled type 2 diabetes: a randomized study. Ann Intern Med. 2005; 143(8):559-69.
Liraglutide + Metformin and TZD
Zinman B, Gerich J, Buse JB, Lewin A, Schwartz S, Raskin P, Hale PM, Zdravkovic M, Blonde L; LEAD-4 Study Investigators. Efficacy and safety of the human glucagon-like peptide-1 analog liraglutide in combination with metformin and thiazolidinedione in patients with type 2 diabetes (LEAD-4 Met+TZD). Diabetes Care. 2009 Jul;32(7):1224- 30.
Liraglutide + Metformin and Sulfonylurea
Russell-Jones D, Vaag A, Schmitz O, Sethi BK, Lalic N, Antic S, Zdravkovic M, Ravn GM, Simó R; Liraglutide Effect and Action in Diabetes 5 (LEAD-5) met+SU Study Group. Liraglutide vs insulin glargine and placebo in combination with metformin and sulfonylurea therapy in type 2 diabetes mellitus (LEAD-5 met+SU): a randomised controlled trial. Diabetologia. 2009 Oct;52(10):2046-55.
Colesevelam
WelcholTM Prescribing Information. Daiichi Sankyo, Inc. October 2009.
Bays HE, Goldberg RB, Truitt KE, Jones MR. Colesevelam hydrochloride therapy in patients with type 2 diabetes mellitus treated with metformin: glucose and lipid effects. Arch Intern Med. 2008 Oct 13;168(18):1975-83.
Goldberg RB, Fonseca VA, Truitt KE, Jones MR. Efficacy and safety of colesevelam in patients with type 2 diabetes mellitus and inadequate glycemic control receiving insulin- based therapy. Arch Intern Med. 2008 Jul 28;168(14):1531-40.
3 of 3 – Glycemic control Algorithm for type 2 diabetes Mellitus nn Adults – revised 07-22-10
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