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