Diabetes Canada | Clinical Practice Guidelines

Recommendation:

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

More than one agent, or insulin, may be required to reach target.

Assess frailty and select appropriate therapeutic goals.

Current medication: Metformin—maximum dose 500mg od. Avoid metformin when GFR <15.

Consider adding SGLT2i for nephroprotection. Efficacy of SGLT2i for glucose lowering reduced if GFR <45.

Stop DPP4-i if GLP1-RA is initiated.

Current medication: insulin. Caution increased risk for hypoglycemia.

Current medication: TZD. Caution fluid retention.

Current medication: SU. Caution increased risk for hypoglycemia due to low eGFR (<30). If on glyburide, discontinue.

Current medication: GLP1-RA. Caution off-label, consider specialist advice.

Current medication: acarbose. Caution off-label, consider specialist advice.

Your patient has ASCVD, add or substitute SGLT2i or GLP1-RA to reduce MACE (Grade A).

More than one agent, or insulin, may be required to reach target.

Assess frailty and select appropriate therapeutic goals.

Current medication: Metformin. Caution metformin not recommended when GFR <30. Suggested maximum dose 500mg bid.

Consider adding SGLT2i for nephroprotection. Efficacy of SGLT2i for glucose lowering reduced if GFR <45.

Stop DPP4-i if GLP1-RA is initiated.

Current medication: insulin. Caution increased risk for hypoglycemia.

Current medication: TZD. Caution fluid retention.

Current medication: SU. Caution increased risk for hypoglycemia due to low eGFR (<30). If on glyburide, discontinue.

Current medication: GLP1-RA. Caution off-label, consider specialist advice.

Current medication: acarbose. Caution off-label, consider specialist advice.

Your patient has ASCVD and HF, add or substitute SGLT2i or GLP1-RA to reduce MACE (Grade A).

More than one agent, or insulin, may be required to reach target.

Assess frailty and select appropriate therapeutic goals.

Current medication: Metformin. Caution metformin not recommended when GFR <30. Suggested maximum dose 500mg bid.

Consider adding SGLT2i for nephroprotection and to reduce risk of hospitalization due to heart failure. Efficacy of SGLT2i for glucose lowering reduced if GFR <45.

Stop DPP4-i if GLP1-RA is initiated.

Current medication: insulin. Caution increased risk for hypoglycemia.

Current medication: TZD. Caution fluid retention.

Current medication: SU. Caution increased risk for hypoglycemia due to low eGFR (<30). If on glyburide, discontinue.

Current medication: GLP1-RA. Caution off-label, consider specialist advice.

Current medication: acarbose. Caution off-label, consider specialist advice.

Your patient has CKD, add or substitute SGLT2i to reduce progression of nephropathy, hospitalization for heart failure (Grade A).

More than one agent, or insulin, may be required to reach target.

Assess frailty and select appropriate therapeutic goals.

Current medication: Metformin. Caution metformin not recommended when GFR <30. Suggested maximum dose 500mg bid.

Consider adding SGLT2i for nephroprotection. Efficacy of SGLT2i for glucose lowering reduced if GFR <45.

Stop DPP4-i if GLP1-RA is initiated.

Current medication: insulin. Caution increased risk for hypoglycemia.

Current medication: TZD. Caution fluid retention.

Current medication: SU. Caution increased risk for hypoglycemia due to low eGFR (<30). If on glyburide, discontinue.

Current medication: GLP1-RA. Caution off-label, consider specialist advice.

Current medication: acarbose. Caution off-label, consider specialist advice.

Your patient has CKD, add or substitute GLP1-RA to reduce MACE (Grade B).

More than one agent, or insulin, may be required to reach target.

Assess frailty and select appropriate therapeutic goals.

Current medication: Metformin. Caution metformin not recommended when GFR <30. Suggested maximum dose 500mg bid.

Consider adding SGLT2i for nephroprotection. Efficacy of SGLT2i for glucose lowering reduced if GFR <45.

Stop DPP4-i if GLP1-RA is initiated.

Current medication: insulin. Caution increased risk for hypoglycemia.

Current medication: TZD. Caution fluid retention.

Current medication: SU. Caution increased risk for hypoglycemia due to low eGFR (<30). If on glyburide, discontinue.

Current medication: GLP1-RA. Caution off-label, consider specialist advice.

Current medication: acarbose. Caution off-label, consider specialist advice.

Your patient has HF, add or substitute SGLT2i to reduce HHF (Grade A).

More than one agent, or insulin, may be required to reach target.

Assess frailty and select appropriate therapeutic goals.

Current medication: Metformin. Caution metformin not recommended when GFR <30. Suggested maximum dose 500mg bid.

Consider adding SGLT2i for nephroprotection. Efficacy of SGLT2i for glucose lowering reduced if GFR <45.

Stop DPP4-i if GLP1-RA is initiated.

Current medication: insulin. Caution increased risk for hypoglycemia.

Current medication: TZD. Caution fluid retention.

Current medication: SU. Caution increased risk for hypoglycemia due to low eGFR (<30). If on glyburide, discontinue.

Current medication: GLP1-RA. Caution off-label, consider specialist advice.

Current medication: acarbose. Caution off-label, consider specialist advice.

Your patient has 2 or more Risk Factors, add or substitute GLP1-RA to reduce MACE. An SGLT2i could be considered to reduce HHF or progression of nephropathy.

More than one agent, or insulin, may be required to reach target.

Assess frailty and select appropriate therapeutic goals.

Current medication: Metformin. Caution metformin not recommended when GFR <30. Suggested maximum dose 500mg bid.

Efficacy of SGLT2i for glucose lowering reduced if GFR <45.

Stop DPP4-i if GLP1-RA is initiated.

Current medication: insulin. Caution increased risk for hypoglycemia.

Current medication: TZD. Caution fluid retention.

Current medication: SU. Caution increased risk for hypoglycemia due to low eGFR (<30). If on glyburide, discontinue.

Current medication: GLP1-RA. Caution off-label, consider specialist advice.

Current medication: acarbose. Caution off-label, consider specialist advice.

Patient preferences

Click the toggles to adjust pharmacotherapy table below based on patient priorities

Is avoiding weight gain important?

Is avoiding hypoglycemia important?

Pharmacotherapy

Drug classes are listed with priority given to drugs with established cardiorenal benefits, cardiorenal safety, low risks for hypoglycaemia or weight gain.

Class	Drug	Usual starting dose
*see renal dosing if GFR<60
Biguanide	Metformin Metformin extended-release
SGLT2 inhibitors	Canagliflozin Dapagliflozin Empagliflozin	100–300mg daily 5–10mg daily 10–25mg daily
GLP1 receptor agonists	Dulaglutide Liraglutide Semaglutide	0.75mg weekly 0.6mg daily 0.25mg weekly
DPP-4 Inhibitors	Linagliptin Saxagliptin Sitagliptin	5mg daily 5mg daily* 100mg daily*
Insulin secretagogue	Sulfonylureas Gliclazide Gliclazide-modified release Glimepiride Glyburide Meglitinides Repaglinide	80mg bid 30mg daily 1–2mg daily 2.5–5mg daily* 0.5–1mg tid
Thiazoladinediones	Pioglitazone	15mg daily
Alpha-glucosidase inhibitor	Acarbose	25–50mg tid with meals
Insulin	See Insulin Prescription Tool

Drugs for Glycemic Management of Type 2 Diabetes Interactive Decision Tool

For Health-Care Providers

STEP 1: Tell us about the person you are caring for

STEP 2: Cardiovascular disease

STEP 3: Risk factors

Recommendation:

Patient preferences

Pharmacotherapy

Metformin	SU/Meglitinide
DPP4-i	SGLT2i
Insulin	GLP1-RA
TZD	Acarbose