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Pharmacologic Management of Type 2 Diabetes

Pharmacologic Management of Type 2 Diabetes. Key Messages If glycemic targets are not achieved within 2 to 3 months of lifestyle management, antihyperglycemic pharmacotherapy should be initiated.

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Pharmacologic Management of Type 2 Diabetes

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  1. Pharmacologic Management of Type 2 Diabetes Key Messages • If glycemic targets are not achieved within 2 to 3 months of lifestyle management, antihyperglycemic pharmacotherapy should be initiated. • Timely adjustments to and/or additions of antihyperglycemic agents should be made to attain target A1C within 6 to 12 months.

  2. Pharmacologic Management of Type 2 Diabetes Key Messages • In patients with marked hyperglycemia (A1C ≥ 9.0%), antihyperglycemic agents should be initiated concomitantly with lifestyle management, and consideration should be given to either initiating combination therapy with 2 agents or initiating insulin.

  3. Pharmacologic Management of Type 2 Diabetes 2008 CPG Recommendations • In people with type 2 diabetes, if glycemic targets are not achieved using lifestyle management within 2 to 3 months, antihyperglycemic agents should be initiated [Grade A, Level 1A (3)]. In the presence of marked hyperglycemia (A1C ≥ 9.0%), antihyperglycemic agents should be initiated concomitantly with lifestyle management, and consideration should be given to initiating combination therapy with 2 agents or initiating insulin treatment in symptomatic individuals [Grade D, Consensus].

  4. Pharmacologic Management of Type 2 Diabetes 2008 CPG Recommendations • If glycemic targets are not attained when a single antihyperglycemic agent is used initially, an antihyperglycemic agent or agents from different classes should be added. The lag period before adding other agent(s) should be kept to a minimum, taking into account the characteristics of the different agents. Timely adjustments to and/or additions of antihyperglycemic agents should be made in order to attain target A1C within 6 to 12 months [Grade D, Consensus].

  5. Pharmacologic Management of Type 2 Diabetes 2008 CPG Recommendations • Pharmacological treatment regimens should be individualized taking into consideration the degree of hyperglycemia and the properties of the antihyperglycemic agents including: effectiveness in lowering BG, durability of glycemic control, side effects, contraindications, risk of hypoglycemia, presence of diabetes complications or comorbidities, and patient preferences [Grade D, Consensus].

  6. Pharmacologic Management of Type 2 Diabetes 2008 CPG Recommendations The following factors and the information shown in Table 1 and Figure 1 should also be taken into account: • Metformin should be the initial drug used in both overweight patients [Grade A, Level 1A (52)] and nonoverweight patients [Grade D, Consensus]. • Other classes of antihyperglycemic agents, including insulin, should be added to metformin, or used in combination with each other, if glycemic targets are not met, taking into account the information in Figure 1 and Table 1 [Grade D, Consensus].

  7. Pharmacologic Management of Type 2 Diabetes 2008 CPG Recommendations • When basal insulin is added to antihyperglycemic agents, long-acting analogues (insulin detemir or insulin glargine) may be considered instead of NPH to reduce the risk of nocturnal and symptomatic hypoglycemia [Grade A, Level 1A (71)].

  8. Pharmacologic Management of Type 2 Diabetes 2008 CPG Recommendations • The following antihyperglycemic agents (listed in alphabetical order), should be considered to lower postprandial BG levels: • Alpha-glucosidase inhibitor [Grade B, Level 2 (10)] • Premixed insulin analogues (i.e. biphasic insulin aspart and insulin lispro/protamine) instead of regular/NPH premixtures [Grade B, Level 2 (72,73)]

  9. Pharmacologic Management of Type 2 Diabetes 2008 CPG Recommendations • DPP-4 inhibitor [Grade A, Level 1 (13,14,74)] • Inhaled insulin [Grade B, Level 2 (20)] • Meglitinides (repaglinide, nateglinide) instead of sulfonylureas [Grade B, Level 2 (75,76)] • Rapid-acting insulin analogues (aspart, glulisine, lispro) instead of short-acting insulin (i.e. regular insulin) [Grade B, Level 2 (21,77,78)].

  10. Pharmacologic Management of Type 2 Diabetes 2008 CPG Recommendations • All individuals with type 2 diabetes currently using or starting therapy with insulin or insulin secretagogues should be counselled about the recognition and prevention of drug-induced hypoglycemia [Grade D, Consensus].

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