Selecting a Treatment Regimen
ÎWhen 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.
intermediate-acting neutral protamine Hagedorn (NPH) because they are associated with less hypoglycemia (A-1).
ÎAntihyperglycemic 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.
ÎWhen 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 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).
ÎIntensification 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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Insulin analogues glargine and detemir are preferred over
