Management of Hyperglycemia in Type 2 Diabetes: A Consensus Algorithm for the Initiation and Adjustment of Therapy

Update regarding thiazolidinediones: a consensus statement from the American Diabetes Association and the European Association for the Study of Diabetes

  1. David M. Nathan, MD12,
  2. John B. Buse, MD, PHD3,
  3. Mayer B. Davidson, MD4,
  4. Ele Ferrannini, MD5,
  5. Rury R. Holman, FRCP6,
  6. Robert Sherwin, MD7 and
  7. Bernard Zinman, MD8
  1. 1Diabetes Center, Massachusetts General Hospital, Boston, Massachusetts
  2. 2Harvard Medical School, Boston, Massachusetts
  3. 3University of North Carolina School of Medicine, Chapel Hill, North Carolina
  4. 4Charles R. Drew University, Los Angeles, California
  5. 5Department of Internal Medicine, University of Pisa, Pisa, Italy
  6. 6Diabetes Trials Unit, Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford University, Oxford, U.K
  7. 7Yale University School of Medicine, New Haven, Connecticut
  8. 8Samuel Lunenfeld Research Institute, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
  1. Address correspondence and reprint requests to David M. Nathan, Diabetes Center, Massachusetts General Hospital, Boston, MA 02114. E-mail: dnathan{at}

The consensus algorithm for the management of type 2 diabetes was developed on behalf of the American Diabetes Association and the European Association for the Study of Diabetes approximately 1 year ago (1,2). This evidence-based algorithm was developed to help guide health care providers to choose the most appropriate treatment regimens from an ever-expanding list of approved medications. The authors continue to endorse the major features of the algorithm, including the need to achieve and maintain glycemia within or as close to the nondiabetic range as is safely possible, the initiation of lifestyle interventions and treatment with metformin at the time of diagnosis, the rapid addition of medications and transition to new regimens when target glycemia is not achieved, and the early addition of insulin therapy in patients who do not meet target A1C levels.

The availability of newly approved medications and the accrual of new clinical trial and other data should inform the algorithm. In this update, we primarily address one important issue that has received much recent attention: our current understanding of the advantages and disadvantages of the thiazolidinediones. In addition, we have revised the original Table 1 to include the dipeptidylpeptidase-4 inhibitor sitagliptin, which was not approved by the U.S. Food and Drug Administration at the time of our original publication (Table 1).

We are mindful of the importance of not changing this consensus guideline in …

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