Pharmacotherapy for Type 2 Diabetes

By Agent and Patient Characteristics

At diagnosis of type 2 diabetes: Start lifestyle intervention (nutrition therapy and physical activity) +/- Metformin

Which of the following applies to your patient?

A1C <8.5%
A1C ≥8.5%
Symptomatic hyperglycemia with metabolic decompensation
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Recommendations:

If not at target in 2-3 months, start/increase metformin.*

Start metformin immediately. Consider initial combination with another antihyperglycemic agent.

Initiate insulin +/- metformin.

If the glycemic target is still not reached, add an agent best suited to the individual. See the following table.

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Individualize the table based on patient characteristics:

Priority: Does your patient have clinical cardiovascular disease? Yes No

What is your patient's renal function (eGFR in mL/min/1.73m2)?

Does your patient have Congestive Heart Failure? Yes No

Does your patient have metabolic bone disease? Yes No

Does your patient currently have pancreatitis? Yes No

Does your patient have a prior history of pancreatitis? Yes No

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*IMPORTANT* This table has been individualized and some medications may have been removed based on patient characteristics.

Sort the table by column:

Click a column title to sort results by that column.

When sorting table by column, rows with equivalent values are sorted alphabetically. Therefore, the row order of equivalent values does not imply a preference. Up and down arrows (↑↓) indicate approximate relative effectiveness. Two or three arrows do not necessarily imply double or triple the effect.

Class Relative A1C lowering Hypoglycemia Weight Effect in Cardiovascular Outcome Trial Other therapeutic considerations Cost
alo=alogliptin; empa=empagliflozin; glar=glargine; lixi=lixisenatide; saxa=saxagliptin; sita=sitagliptin
Alpha-glucosidase inhibitor (acarbose) Rare neutral to ↓   Improved postprandial control, GI side-effects $$
Incretin agent: DPP-4 Inhibitors ↓ ↓ Rare neutral to ↓ Neutral
(alo, saxa, sita)
Caution with saxagliptin in heart failure $$$
Incretin agent: GLP-1 receptor agonists ↓ ↓ to ↓ ↓ ↓ Rare ↓ ↓ Neutral (lixi) GI side-effects $$$$
Insulin ↓ ↓ ↓ Yes ↑ ↑ Neutral (glar) No dose ceiling, flexible regimens $-$$$$
Insulin secretagogue: Meglitinide ↓ ↓ Yes   Less hypoglycemia in context of missed meals but usually requires TID to QID dosing $$
Insulin secretagogue: Sulfonylurea ↓ ↓ Yes   Gliclazide and glimepiride associated with less hypoglycemia than glyburide $
SGLT2 inhibitors ↓ ↓ to ↓ ↓ ↓ Rare ↓ ↓ Superiority (empa in T2DM patients with clinical CVD) Genital infections, UTI, hypotension, dose-related changes in LDL-C, caution with renal dysfunction and loop diuretics, dapagliflozin not to be used if bladder cancer, rare diabetic ketoacidosis (may occur with no hyperglycemia); caution in the elderly $$$
TZD ↓ ↓ Rare ↑ ↑ Neutral CHF, edema, fractures, rare bladder cancer (pioglitazone), cardiovascular controversy (rosiglitazone), 6-12 weeks required for maximal effect $$
Weight loss agent (orlistat) None   GI side effects $$$

*Caution: reduce dose of metformin.*

  CKD 1 & 2 eGFR ≥60 mL/min CKD 3 eGFR 30-59 mL/min CKD 4 eGFR 15-29 mL/min CKD 5 eGFR <15 mL/min or dialysis Comments
Metformin No dose adjustment Reduce dose Use alternative agent See “Sick Day Medication List” (Appendix 7). Risk of drug accumulation with declining renal function, especially if acute.

*Caution: eliminate metformin from treatment plan.*

*Caution: Metformin eliminated from treatment plan because of renal failure.*

*Caution: Acarbose eliminated from treatment plan because of renal failure.*

*Caution: Acarbose eliminated from treatment plan because of reduced eGFR.*

*Caution: DPP-4 inhibitors eliminated from treatment plan because of current history of pancreatitis.*

*Caution: GLP-1 receptor agonists eliminated from treatment plan because of reduced eGFR.*

*Caution: GLP-1 receptor agonists eliminated from treatment plan because of current pancreatitis.*

*Caution: GLP-1 receptor agonists eliminated from treatment plan. Do not restart if pancreatitis developed while on the GLP-1 receptor agonist. Use liraglutide with caution in patients with a history of pancreatitis. Consider antihyperglycemic agents other than exenatide in patients with a history of pancreatitis.*

*Caution: Thiazoledinediones eliminated from treatment plan because of Congestive Heart Failure or metabolic bone disease.*

*Caution: SGLT2s eliminated from treatment plan because of reduced eGFR.*

*In people with clinical cardiovascular disease in whom glycemic targets are not met, a SGLT2 inhibitor with demonstrated cardiovascular outcome benefit should be added to antihyperglycemic therapy to reduce the risk of cardiovascular and all-cause mortality [Grade A, Level 1A for empagliflozin].*

If not at glycemic targets

• Add another agent from a different class • Add/Intensify insulin regimen

Make timely adjustments to attain target A1C within 3-6 months

This is only to be used as a decision support tool and is subject to these terms.
For more information, please see the disclaimer.