Treatment
ÎÎIn most patients, begin with lifestyle changes. Metformin monotherapy
is added at, or soon after, diagnosis (unless there are explicit
contraindications).
ÎÎIf the HbA1c target is not achieved after ~3 months, consider one of
the five treatment options combined with metformin: a sulfonylurea,
TZD, DPP-4 inhibitor, GLP-1 receptor agonist, or basal insulin. (The
order in Figure 6 is determined by historical introduction and route of
administration and is not meant to denote any specific preference.)
• Choice is based on patient and drug characteristics, with the over-riding goal of
improving glycemic control while minimizing side effects. Shared decision making
with the patient may help in the selection of therapeutic options. Figure 6 displays
drugs commonly used in the U.S. and/or Europe.
ÎÎRapid-acting secretagogues (meglitinides) may be used in place of
sulfonylureas.
• Other drugs not shown (α-glucosidase inhibitors, colesevelam, dopamine agonists,
pramlintide) may be used where available in selected patients but have modest
efficacy and/or limiting side effects.
ÎÎIn patients intolerant of, or with contraindications for, metformin,
select initial drug from other classes depicted in Figure 6 and
proceed accordingly.
• Insulin is likely to be more effective than most other agents as a third-line therapy,
especially when HbA1c is very high (eg, ≥ 9.0%).
• The therapeutic regimen should include some basal insulin before moving to more
complex insulin strategies (Figure 7).
• Dashed arrow line on the left-hand side of Figure 6 denotes the option of a more
rapid progression from a two drug combination directly to multiple daily insulin
doses in those patients with severe hyperglycemia (eg, HbA1c ≥ 10.0-12.0%).
6
