Mount Carmel Health Partners Clinical Guidelines Diabetes Type II - Page 3

Diabetes Type 2 Clinical Guideline: Treatment should begin by making therapeutic lifestyle changes to include weight reduction, diet modification (reduce saturated fats and simple carbohydrates, and increase fiber and complex carbohydrates), reduction in alcohol consumption, cessation of tobacco use, and increased physical activity levels. Table 1 -- Medication Management Healthy eating, weight control, increased physical activity, and diabetes education Monotherapy Efficacy Hypo risk Weight Metformin High Low risk Metformin is contraindicated in patients with a estimated glomerular filtration rate (eGFR) of < 30 mL/min/1.73m². (See Table 2) Neutral/loss Side effects GI/lactic acidosis Costs Low If A1C target is not achieved after ~3 months of monotherapy, proceed to 2-drug combination. (Order is not meant to denote any specific preference; choice is dependent upon a variety of patient– and disease– specific factors.) Dual Therapy† Efficacy Hypo risk Weight Side effects Costs Metformin + Metformin + Metformin + Metformin + Metformin + Metformin + Sulfonylurea Thiazolidinedione DPP-4 inhibitor SGLT2 inhibitor GLP-1 receptor agonist Insulin (basal) High High Intermediate Intermediate High Highest Moderate risk Low risk Low risk Low risk Low risk High risk Gain Gain Neutral Loss Loss Gain Hypoglycemia Edema, HF, Fxs Rare GU, dehydration GI Hypoglycemia Low Low High High High Variable If A1C target is not achieved after ~3 months of dual therapy, proceed to 3-drug combination. (Order is not meant to denote any specific preference; choice is dependent upon a variety of patient– and disease– specific factors.) Triple Therapy Metformin + Metformin + Metformin + Metformin + Metformin + Metformin + Sulfonylurea + Thiazolidinedione + DPP-4 inhibitor + SGLT2 inhibitor + GLP-1 receptor agonist + Insulin (basal) + TZD SU SU SU SU TZD or DPP-4-i or DPP-4-i or TZD or TZD or TZD or DPP-4-i or SGLT2-i or SGLT2-i or SGLT2-i or DPP-4-i or Insulin§ or SGLT2-i or GLP-1-RA or GLP-1-RA or Insulin§ or Insulin§ or Insulin§ or Insulin§ or GLP-1-RA If A1C target is not achieved after ~3 months of triple therapy and patient: 1) is on oral combination, move to injectables; 2) is on GLP-1-RA, add basal insulin; or 3) is on optimally titrated basal insulin, add GLP-1-RA or mealtime insulin. In refractory patients, consider adding TZD or SGLT2-i. Combination Injectable Therapy‡ Metformin + Basal insulin + Mealtime Insulin or GLP-1-RA Antihyperglycemic therapy in type 2 diabetes: general recommendations. The order in the chart was determined by historical availability and the route of administration, with injectables to the right; it is not meant to denote any specific preference. Potential sequences of antihyperglycemic therapy for patients with type 2 diabetes are displayed, with the usual transition moving vertically from top to bottom (although horizontal movement within therapy stages is also possible, depending on the circumstances). DPP-4-i: DPP-4; fxs: fractures; GI: gastrointestinal; GLP-1-RA: GLP-1 receptor agonist; GU: genito-urinary; HF: heart failure; hypo: hypoglycemia; SGLT2-i: SGLT2 inhibitor; SU: sulfonylurea; TZD: thiazolidinedione. †Consider starting at this stage when A1C is ≥ 9%. ‡Consider starting at this stage when blood glucose is ≥ 300-350 mg/dL (16.7-19.4 mmol/L) and/or A1c is ≥ 10-12%, especially if symptomatic or catabolic features are present, in which case basal insulin + mealtime insulin is the preferred initial regimen. §Usually a basal insulin (NPH, glargine, detemir, degludec). Source: “Diabetes Care.” The Journal of Clinical and Applied Research and Education, January 2015. Diabetes Type II - 3