Pharmacotherapy for Type 2 Diabetes

Individualize by Agent and Patient Characteristics

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

Is this patient newly diagnosed with type 2 diabetes?

Yes No

Which of the following applies to your patient?

A1C <1.5% above their target
A1C ≥1.5% above their target
Patient has metabolic decompensation

Are glycemic targets now being met?

Yes No

Does this patient have clinical cardiovascular disease?

Yes No

What medications is this patient currently taking?

Acarbose Meglitinide
DPP4-i Metformin
GLP1RA SU
Insulin - basal SGLT2i
Insulin - mealtime TZD

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What is the patient's eGFR?

  mL/min/1.73m2Submit
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Recommendation:

Start healthy behaviour interventions; start metformin if glycemic targets not met within 3 months.

Start healthy behaviour interventions; start metformin immediately; consider starting a second agent concurrently.

Start healthy behaviour interventions; start insulin immediately (with or without metformin).

Encourage ongoing healthy behaviours and maintenance of glycemic control.

Start antihyperglycemic agent with demonstrated CV benefit (empagliflozin, liraglutide, canagliflozin).

Start antihyperglycemic agent with demonstrated CV benefit (liraglutide).

Start healthy behaviour interventions.

Start healthy behaviour interventions; consider starting two agents concurrently.

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

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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 Effect on CV outcomes (people with diabetes and CVD) Likelihood of hypoglycemia Effect on weight Relative A1C lowering when added to metformin Cost Renal considerations Other therapeutic considerations
Alpha-glucosidase inhibitor (acarbose)   Rare Neutral $$   GI side effects; requires TID dosing
DPP-4 Inhibitors Neutral: alogliptin, saxagliptin, sitagliptin Rare Neutral ↓ ↓ $$$   Caution with saxagliptin and heart failure; Rare joint pain
GLP1 receptor agonists Liraglutide: Superior
Exenatide LAR and lixisenatide: Neutral
Rare ↓ ↓ ↓ ↓ to ↓ ↓ ↓ $$$$   GI side-effects
Gallstone disease
Contraindicated: Personal or family history of MTC or MEN2
Requires SC injection
Insulin Neutral: glargine
Non-inferior to glargine: degludec
High ↑ ↑ ↓ ↓ ↓ ↓ $-$$$$   No dose ceiling, flexible regimens
Requires SC injection
Insulin secretagogue: Meglitinide   Some ↓ ↓ $$   Reduced post-prandial glycemia; requires TID-QID dosing
Metformin   Rare N/A $   Some GI side effects
Insulin secretagogue: Sulfonylurea   Some ↓ ↓ $   Gliclazide and glimepiride associated with less hypoglycemia than glyburide
Poor durability
SGLT2 inhibitors Canagliflozin and empagliflozin: superior Rare ↓ ↓ ↓ ↓ to ↓ ↓ ↓ $$$   Genital infections, UTI, hypotension
Caution with renal dysfunction and loop diuretics, elderly
Contraindications: Dapagliflozin and bladder cancer, canagliflozin and prior lower extremity amputation
Rare DKA (may occur without hyperglycemia)
Thiazoladinediones Neutral Rare ↑ ↑ ↓ ↓ $$   CHF, edema, fractures, cardiovascular controversy (rosiglitazone)
Contraindications: pioglitazone and bladder cancer

*CAUTION* alpha glucosidase inhibitor (acarbose) eliminated from treatment plan on basis of low eGFR.

*CAUTION* metformin eliminated from treatment plan on basis of low eGFR.

*CAUTION* SGLT2i eliminated from treatment plan on basis of low eGFR.

*CAUTION* sulfonylreas eliminated from treatment plan on basis of low eGFR.

*CAUTION* TZD eliminated from table. Use of TZD with insulin is contraindicated

*CAUTION* SU eliminated from table. Use of a SU and meglitinide together is contraindicated; SU generally has more glucose lowering but may have more side effects (hypoglycemia)

*CAUTION* Meglitinide eliminated from table. Use of a SU and meglitinide together is contraindicated; SU generally has more glucose lowering but may have more side effects (hypoglycemia)

*CAUTION* GLP1RA eliminated from table. Use of a DPP4-i and a GLP1RA together is contraindicated; GLP1RA generally has more glucose lowering but may have more side effects (GI)

*CAUTION* DPP4-i eliminated from table. Use of a DPP4-i and a GLP1RA together is contraindicated; GLP1RA generally has more glucose lowering but may have more side effects (GI)

*CAUTION* Insulin eliminated from table. Use of TZD with insulin is contraindicated

*CAUTION* SU and meglitinide eliminated from table. Use of a SU or meglitinide when on mealtime insulin is not helpful

Note: Alpha-glucosidase inhibitor (acarbose) eliminated from table because patient is already taking a drug from that class.

Note: DPP4-i eliminated from table because patient is already taking a drug from that class.

Note: GLP1RA eliminated from table because patient is already taking a drug from that class.

Note: Insulin eliminated from table because patient is already taking a drug from that class. You could intensify insulin therapy.

Note: Meglitinide eliminated from table because patient is already taking a drug from that class.

Note: Metformin eliminated from table because patient is already taking a drug from that class.

Note: SU eliminated from table because patient is already taking a drug from that class.

Note: SGLT2i eliminated from table because patient is already taking a drug from that class.

Note: TZD eliminated from table because patient is already taking a drug from that class.

This is only to be used as a decision support tool and is subject to these terms.
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