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 +
DPP-4 Inhibitor
intermediate low risk neutral rarec high
Metformin +
GLP-1 receptor agonist
high low risk loss Glc high
Metformin +
Insulin (usually basal)
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 TZD
Insulind
Metformin +
GLP-1 receptor agonist
+
or or
SUb TZD
Insulind
Metformin +
Insulin (usually basal)
+ TZD
or or
DPP-4-i 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:
(multiple daily doses) Insuline
d Usually a basal insulin (NPH, glargine, detemir) in combination with noninsulin agents. e
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.).
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