• A1C of ≥7% should serve as a call to action to initiate or change therapy to reach the nondiabetic range or, at a minimum, to decrease A1C to <7%.[1]
• Maintaining glycemic levels as close to the nondiabetic range as possible has had a powerful, beneficial impact on diabetes-specific complications.[1]
• Abnormalities other than hyperglycemia, such as dyslipidemia and hypertension, were also considered in forming the treatment algorithm, as treatment of such abnormalities has been shown to improve microvascular and cardiovascular complications.[2-4]
• Some therapies directed at lowering glucose levels have additional benefits with regard to CVD risk factors, while others lower glucose without additional
  benefits.[1]
• TZDs either have a beneficial or neutral effect on atherogenic lipid profiles, with pioglitazone having a more beneficial effect than rosiglitazone.[1,5]

Factors for selecting specific diabetes interventions[1]

• The choice of antihyperglycemic agents should be based on:
  – Effectiveness in lowering glucose
  – Safety profiles
  – Expense
  – Extraglycemic effects that may reduce long-term complications
  – Tolerability
• The overall emphasis in selecting an intervention should be its ability to achieve and maintain glycemic goals.
• Addition of medications is the rule, not the exception, if treatment goals are to be met over time.

Qualities of monotherapy medications[1]

Adapted from Nathan DM, et al. Diabetes Care. 2006;29:1963-1972.

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*Severe hypoglycemia is relatively infrequent with sulfonylurea therapy. The longer-acting agents (eg, chlorpropamide, glyburide [glibenclamide], and sustained-release glipizide) are more likely to cause hypoglycemia than glipizide, glimepiride, and gliclazide.

New algorithm steps[1]

Step 1—Metformin therapy should be:

• Initiated concurrently with lifestyle intervention at diagnosis.
• Titrated to its maximally effective dose over 1–2 months.

Step 2—Another medication (insulin, a sulfonylurea, or a TZD) should be added within 2–3 months of the initiation of therapy or at any time when A1C goal is not achieved.

• The A1C level will determine in part which agent is selected next.

Step 3—When A1C is close to goal (<8.0%), addition of a third oral agent could be considered.

Adapted from Nathan DM, et al. Diabetes Care. 2006;29:1963-1972.

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*Check A1C every 3 months until <7% and then at least every 6 months.

†See Fig. 1 in Nathan DM, et al, for initiation and adjustment of insulin.

‡Although three oral agents can be used, initiation and intensification of insulin therapy is preferred based on effectiveness and expense.

• Many patients may be managed effectively with monotherapy; however, the progressive nature of the disease will require the use of combination therapy in many, if not most, patients over time to achieve and maintain glycemia in the target range.
• Pramlintide, exenatide, α-glucosidase inhibitors, and the glinides are not included in this algorithm, owing to their generally lower overall glucose-lowering effectiveness, limited clinical data, and/or relative expense.

Study conclusions[1]

The guidelines and goals to effectively treat type 2 diabetes should include:

• Achievement and maintenance of normal glycemic goals.
• Initial therapy with lifestyle intervention and metformin.
• Rapid addition of medications (insulin, a sulfonylurea, or a TZD), and transition to new regimens, when target glycemic goals are not achieved or sustained.
• Early addition of insulin therapy in patients who do not meet target goals.

For direct link to published ADA treatment algorithm, click here.

Read more.