Stepwise Approach to Selecting Treatments for Type 2 Diabetes

Pharmacist's Letter/ Prescriber's Letter June 2007, Vol 23, No 230622

1. Diagnosis of Type 2 DM
   
    
2. Counsel regarding lifestyle modification (Weight Loss, Exercise); Expect decrease in HbA1C 1-2%) and initiate Metformin (glucophage) 500 mg PO QD or BID; titrate to 850 to 1000 mg BID (expect decrease in HbA1c 1.5%)
   
    
3. If HbA1c 7% or greater 3 months later:

• Add sulfonylurea (Amaryl/glimeperide, Glynase/glyburide, Glucotrol/glipizide); expected decrease in HbA1c 1.5%)
• OR basal insulin (bedtime intermediate-acting insulin or bedtime or morning long-acting insulin); expect decrease in HbA1c of 1.5-2.5%
• OR pioglitazone (actos); expect decrease in HbA1C 0.5-1.4%

4. If HbA1c 7% or greater 3 months later:

• Add additional agent (sulfonylurea or insulin or glitazone)
• OR intensify insulin for those on insulin

5. If HbA1c 7% or greater 3 months later:

• In patients not yet receiving insulin, add basal insulin or intensify insulin in those already receiving insulin

6. If HbA1c 7% or greater 3 months later:

• Metformin + Intensive insulin with/without glitazone

When prandial rapid or very-rapid acting insulin is added, insulin secretagogues such as the sulfonylureas or the glinides (repaglinide, nateglinide) should be discontinued.

• Consider insulin as initial therapy (with lifestyle modification) in patients with fasting glucose greater than 250 mg/dL or HbA1c greater than 10% or those with ketonuria or symptoms of hyperglycemia
• When initiating insulin, start with a bedtime dose of an intermediate-acting insulin or once-daily long-acting insulin.  Initate with 10U or 0.2 U/kg.  Check fasting glucose concentrations and increase by approximately 2 U (4U if fasting glucoses are greater than 180 mg/dL) every 3 days, until fasting glucoses are less than 130 mg/dL.  If HbA1c continues to be 7% or greater after 2-3 months, with well controlled fasting glucose concentrations, consider checking pre-meal glucose concentrations.