Treatment
ÎIn most patients, begin with lifestyle changes. Metformin monotherapy is added at, or soon after, diagnosis (unless there are explicit contraindications).
ÎIf 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.
ÎRapid-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.
ÎIn 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%).
• 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%).
• The therapeutic regimen should include some basal insulin before moving to more complex insulin strategies (Figure 7).
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