Pharmacologic Management of Type 2 Diabetes

Canadian Diabetes Association Clinical Practice Guidelines Expert Committee

William Harper MD, FRCPC Maureen Clement MD, CCFP Ronald Goldenberg MD, FRCPC, FACE Amir Hanna MB, BCh, FRCPC, FACP Andrea Main BScPhm, CDE Ravi Retnakaran MD, MSc, FRCPC Diana Sherifali RN, PhD, CDE Vincent Woo MD, FRCPC Jean-François Yale MD, CSPQ, FRCPC

  • Key Messages
  • Recommendations
  • Figures
  • Highlights
  • Full Text
  • References

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 glycated hemoglobin (A1C) within 3 to 6 months.
  • In patients with marked hyperglycemia (A1C ≥8.5%), antihyperglycemic agents should be initiated concomitantly with lifestyle management, and consideration should be given to initiating combination therapy with 2 agents, 1 of which may be insulin.
  • Unless contraindicated, metformin should be the initial agent of choice, with additional antihyperglycemic agents selected on the basis of clinically relevant issues, such as contraindication to drug, glucose lowering effectiveness, risk of hypoglycemia and effect on body weight.

Highlights of Revisions

  • Metformin may be used at the time of diagnosis.
  • A glycated hemoglobin (A1C) ≥ 8.5% at diagnosis should receive immediate pharmacotherapy and, perhaps, combination therapy.
  • Achieve A1C target within 3 to 6 months of diagnosis.
  • Better description of the parameters to consider when selecting antihyperglycemic agent(s) for a particular individual.
  • New algorithm for the management of hyperglycemia in type 2 diabetes, as well as an updated table of antihyperglycemic agents for type 2 diabetes.
  • New appendix of cost for pharmacological agents (for type 1 and type 2 diabetes) has been added.

Figure 1
Management of hyperglycemia in type 2 diabetes.

A1C, glycated hemoglobin; CHF, congestive heart failure; DPP-4, dipeptidyl peptidase 4; GI, gastrointestinal; GLP-1, glucagon-like peptide 1; TZD, thiazolidinedione.

Recommendations

  1. 1.In people with type 2 diabetes, if glycemic targets are not achieved using lifestyle management within 2 to 3 months, antihyperglycemic agent therapy should be initiated [Grade A, Level 1A (1)]. Metformin may be used at the time of diagnosis, in conjunction with lifestyle management (Grade D, Consensus).
    1. i.If A1C ≥8.5%, antihyperglycemic agents should be initiated concomitantly with lifestyle management, and consideration should be given to initiating combination therapy with 2 agents, one of which may be insulin (Grade D, Consensus).
    2. ii.Individuals with symptomatic hyperglycemia and metabolic decompensation should receive an initial antihyperglycemic regimen containing insulin [Grade D, Consensus].
  2. 2.Metformin should be the initial drug used [Grade A, Level 1A (2,3) for overweight patients; Grade D, Consensus for nonoverweight patients].
  3. 3.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], and these adjustments to and/or additions of antihyperglycemic agents should be made in order to attain target A1C within 3 to 6 months [Grade D, Consensus].
  4. 4.Choice of pharmacological treatment agents should be individualized, taking into consideration [Grade D, Consensus]:
    • Patient characteristics:
      • Degree of hyperglycemia
      • Presence of comorbidities
      • Patient preference and ability to access treatments
    • Properties of the treatment:
      • Effectiveness and durability of lowering BG
      • Risk of hypoglycemia
      • Effectiveness in reducing diabetes complications
      • Effect on body weight
      • Side effects
      • Contraindications
  5. 5.When basal insulin is added to antihyperglycemic agents, long-acting analogues (detemir or glargine) may be used instead of intermediate-acting NPH to reduce the risk of nocturnal and symptomatic hypoglycemia [Grade A, Level 1A (4-6)].
  6. 6.When bolus insulin is added to antihyperglycemic agents, rapid-acting analogues may be used instead of regular insulin to improve glycemic control [Grade B, Level 2 (7)] and to reduce the risk of hypoglycemia [Grade D, Consensus)].
  7. 7.All individuals with type 2 diabetes currently using or starting therapy with insulin or insulin secretagogues should be counseled about the prevention, recognition and treatment of drug-induced hypoglycemia [Grade D, Consensus].

References

  1. UK Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 1998;352: 837-53.
  2. UK Prospective Diabetes Study (UKPDS) Group. Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34). Lancet 1998;352:854-65.
  3. Holman RR, Paul SK, Bethel MA, et al. 10-year follow-up of intensive glucose control in type 2 diabetes. N Engl J Med 2008;359:1577-89.
  4. Sumeet R, Singh SR, Ahmad F, et al. Efficacy and safety of insulin analogues for the management of diabetes mellitus: a meta-analysis. CMAJ 2009;180: 385-97.
  5. Horvath K, Jeitler K, Berghold A, et al. A long-acting insulin analogues versus NPH insulin (human isophane insulin) for type 2 diabetes mellitus (Review). Cochrane Database Syst Rev 2007;2:CD005613.
  6. Monami M, Marchionni N, Mannucci E. Long-acting insulin analogues versus NPH human insulin in type 2 diabetes: a meta-analysis. Diabetes Res Clin Pract 2008;81:184-9.
  7. Mannucci E, Monami M, Marchionni N. Short-acting insulin analogues vs. regular human insulin in type 2 diabetes: a meta-analysis. Diabetes Obes Metab 2009;11:53-9.

 

Reproduced with permission from Canadian Journal of Diabetes © 2013 Canadian Diabetes Association. To cite this article, please refer to For citation.

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