Healthy eating, weight control, increased physical activity
Metformin
high
low risk
neutral/loss
GI/lactic acidosis
low
If needed to reach individualized HbA1c target after ~3 months, proceed to two-drug
combination (order not meant to denote any specific preference):
Metformin
+
Metformin
+
Metformin
+
DPP-4 Inhibitor
GLP-1 receptor
agonist
Insulin (usually
basal)
intermediate
low risk
neutral
rarec
high
high
low risk
loss
Glc
high
highest
high risk
gain
hypoglycemiac
variable
If needed to reach individualized HbA1c target after ~3 months, proceed to three-drug
combination (order not meant to denote any specific preference):
Metformin
+
DPP-4 Inhibitor
+
or
or
SUb
Metformin
+
GLP-1 receptor
agonist
+
SUb
or
TZD
Insulin
d
or
TZD
Insulin
d
Metformin
+
Insulin (usually
basal)
+
TZD
or
DPP-4-i
or GLP-1-RA
If combination therapy that includes basal insulin has failed to achieve HbA1c target after
3-6 months, proceed to a more complex insulin strategy, usually in combination with one
or two non-insulin agents:
Insuline
(multiple daily doses)
d
e
Usually a basal insulin (NPH, glargine, detemir) in combination with noninsulin agents.
Certain noninsulin agents may be continued with insulin (see full text guidelines). Refer to Figure 7
for details on regimens. Consider beginning at this stage if patient presents with severe hyperglycemia
(≥ 300-350 mg/dL [≥ 16.7-19.4 mmol/L]; HbA1c ≥ 10.0-12.0%) with or without catabolic features
(weight loss, ketosis, etc.).
5
