Selecting a Treatment Regimen
ÎÎWhen insulin therapy is indicated in patients with T2DM to target FPG,
therapy with long-acting basal insulin should be the initial choice in
most cases. Insulin analogues glargine and detemir are preferred over
intermediate-acting neutral protamine Hagedorn (NPH) because they
are associated with less hypoglycemia (A-1).
ÎÎAntihyperglycemic agents may be broadly categorized by whether
they predominantly target FPG or PPG levels. These effects are not
exclusive; drugs acting on FPG passively reduce PPG, and drugs acting
on PPG passively reduce FPG, but these broad categories can aid in
therapeutic decision-making.
>> TZDs and sulfonylureas (SUs) are examples of oral agents primarily affecting FPG.
>> Metformin and incretin enhancers (dipeptidyl-peptidase 4 inhibitors [DPP-4
inhibitors]) also favorably affect FPG.
ÎÎWhen postprandial hyperglycemia is present, glinides and/or
α-glucosidase inhibitors, short- or rapid-acting insulin, and metformin
should be considered (A-1).
>> Incretin-based therapy (DPP-4 inhibitors and glucagonlike peptide 1 [GLP-1]
receptor agonists, especially short-acting GLP-1 agonists) also target postprandial
hyperglycemia in a glucose-dependent fashion, which reduces the risks of
hypoglycemia.
>> When control of postprandial hyperglycemia is needed and insulin is indicated,
rapid-acting insulin analogues are preferred over regular human insulin because
they have a more rapid onset and offset of action and are associated with less
hypoglycemia (A-1).
▶▶ Pramlintide can be used as an adjunct to prandial insulin therapy to reduce
postprandial hyperglycemia, HbA1c, and weight (A-1).
ÎPremixed insulin (fixed combination of shorter- and longer-acting
Î
components) analogue therapy may be considered for patients in whom
adherence to a drug regimen is an issue. However, these preparations
lack component dosage flexibility and may increase the risk for
hypoglycemia compared with basal insulin or basal-bolus insulin (D-4).
>> Basal-bolus insulin therapy is flexible and is recommended for intensive insulin
therapy (B-3).
ÎÎIntensification of pharmacotherapy requires glucose monitoring and
medication adjustment at appropriate intervals when treatment goals
are not achieved or maintained (D-4).
>> Most patients with an initial HbA1c level > 7.5% will require combination therapy
using agents with complementary mechanisms of action (D-4). The AACE
algorithm outlines treatment choices on the basis of the current HbA1c level (D-4).
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