The American Diabetes Association (ADA) recommends metformin as the first-line treatment for type 2 diabetes. Metformin monotherapy should be initiated at the time of diagnosis for most patients unless there are contraindications. A synopsis of the ADA’s recommendations on pharmacologic approaches to glycemic treatment of type 2 diabetes is published in Annals of Internal Medicine.
The evidence suggests that metformin is effective, safe, and inexpensive and may reduce the risk for cardiovascular events and death in patients with diabetes. However, if the patient does not tolerate or has contraindications to metformin, another option should be considered. For patients with an HbA1c level of 9 percent or greater who are not acutely symptomatic, initiation of dual combination therapy should be considered to more quickly achieve the target HbA1c level. If the patient has a random glucose level of 16.7 mmol/L or greater or an HbA1c level of 10 percent or greater and has acute symptoms of polyuria, polydipsia, or weight loss, combination therapy that includes insulin should be considered.
Providers should assess whether the HbA1c target has been achieved within approximately 3 months of therapy initiation. If not, therapy should be intensified.
When or if patients need insulin therapy, a safe and simple approach is to prescribe patients 10 units of basal insulin per day and increase the dose by 10 percent to 15 percent once or twice weekly until the fasting blood glucose target is met. Insulin is typically used with metformin and sometimes one additional non-insulin agent. If target HbA1c level is still not met, there are several other insulin products that can be considered, including concentrated insulin products, inhaled insulin, and combination injectable therapy. Physicians should use a patient-based approach and refer to the ADA’s recommendation chart to help determine which regimen is best.
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More information: Annals of Internal Medicine, http://annals.org/aim/article/doi/10.7326/M16-2937
Journal reference: Annals of Internal Medicine search and more info website
Provided by: American College of Physicians search and more info
March 13, 2017