Medical Management of Hyperglycemia in Type 2 Diabetes: A Consensus Algorithm for the Initiation and Adjustment of Therapy: A consensus statement of the American Diabetes Association and the European Association for the Study of Diabetes

Reviews/Commentaries/ADA Statements

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

¹Diabetes Center, Massachusetts General Hospital, Boston, Massachusetts
²University of North Carolina School of Medicine, Chapel Hill, North Carolina
³Clinical Center for Research Excellence, Charles R. Drew University, Los Angeles, California
⁴Department of Internal Medicine, University of Pisa, Pisa, Italy
⁵Diabetes Trials Unit, Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford University, Oxford, U.K.
⁶Department of Internal Medicine and Yale Center for Clinical Investigation, Yale University School of Medicine, New Haven, Connecticut
⁷Samuel Lunenfeld Research Institute, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada

Diabetes Care 2009 Jan; 32(1): 193-203. https://doi.org/10.2337/dc08-9025

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Figure 1—
Initiation and adjustment of insulin regimens. Insulin regimens should be designed taking lifestyle and meal schedule into account. The algorithm can only provide basic guidelines for initiation and adjustment of insulin. See reference 90 for more detailed instructions. ^aPremixed insulins not recommended during adjustment of doses; however, they can be used conveniently, usually before breakfast and/or dinner, if proportion of rapid- and intermediate-acting insulins is similar to the fixed proportions available. bg, blood glucose.
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Figure 2—
Algorithm for the metabolic management of type 2 diabetes; Reinforce lifestyle interventions at every visit and check A1C every 3 months until A1C is <7% and then at least every 6 months. The interventions should be changed if A1C is ≥7%. ^aSulfonylureas other than glybenclamide (glyburide) or chlorpropamide. ^bInsufficient clinical use to be confident regarding safety. See text box, entitled titration of metformin. See Fig. 1 for initiation and adjustment of insulin. CHF, congestive heart failure.

Table 1—

Summary of glucose-lowering interventions

Intervention	Expected decrease in A1C with monotherapy (%)	Advantages	Disadvantages
Tier 1: well-validated core
Step 1: initial therapy
Lifestyle to decrease weight and increase activity	1.0–2.0	Broad benefits	Insufficient for most within first year
Metformin	1.0–2.0	Weight neutral	GI side effects, contraindicated with renal insufficiency
Step 2: additional therapy
Insulin	1.5–3.5	No dose limit, rapidly effective, improved lipid profile	One to four injections daily, monitoring, weight gain, hypoglycemia, analogues are expensive
Sulfonylurea	1.0–2.0	Rapidly effective	Weight gain, hypoglycemia (especially with glibenclamide or chlorpropamide)
Tier 2: less well validated
TZDs	0.5–1.4	Improved lipid profile (pioglitazone), potential decrease in MI (pioglitazone)	Fluid retention, CHF, weight gain, bone fractures, expensive, potential increase in MI (rosiglitazone)
GLP-1 agonist	0.5–1.0	Weight loss	Two injections daily, frequent GI side effects, long-term safety not established, expensive
Other therapy
α-Glucosidase inhibitor	0.5–0.8	Weight neutral	Frequent GI side effects, three times/day dosing, expensive
Glinide	0.5–1.5^a	Rapidly effective	Weight gain, three times/day dosing, hypoglycemia, expensive
Pramlintide	0.5–1.0	Weight loss	Three injections daily, frequent GI side effects, long-term safety not established, expensive
DPP-4 inhibitor	0.5–0.8	Weight neutral	Long-term safety not established, expensive