Managed Care - October 2008 - (Page 44) FIGURE 4 Type 2 diabetes mellitus treatment guide Created for the University of Pennsylvania Diabetes Disease Management Program by Stanley Schwartz, MD, under the auspices of David Horowitz, MD. Pathophysiologic approach to hyperglycemia 1. Consider therapies for prevention Principles of Guideline 2. Early therapy, even with IFG, IGT 3. Fast therapeutic changes (2–4 weeks) 4. Avoid hypoglycemia Asymptomatic Prevention 5.6 5. Don’t forget diet, exercise, and no smoking 6. Combination frequently required 7. When using insulin, use with insulin sensitizing agent, if possible Symptomatic Diabetes Out of Control A1C 12.0 IGT Diabetes 8.5 Monotherapy metformin, pilglitazone, or incretin (or secretagogue) Combination therapy 2 of 4 or 3 of 4 — metformin, pioglitazone, incretin (secretagogue) Insulin any point in time, but with any/all (met, pio, incretin) Diet and exercise Choices based on matching drug and patient characteristics TZDPioglitazone Incretin Exenatide/DPP4-I Secretagogue SUs | Glinides Repag | netag Metformin Practical Speed of action FBS-PPG Goals-Priorities No hypoglycemia CV benefit Weight β-Cell preservation Special populations Elderly Renal disease (RD) Edema CHF (class 3,4) ?> age 70, not > age 80 Not if Cr>1.4 F, 1.5 M Use Can use ↓ Neutral ↑ Unknown Slow FBS Slow FBS-PPG Fast PPG/FBS-PPG Fast FBS-PPG | FBS-PPG | PPG ↑ ↓ /Neutral ↑ No (increased apoptosis) Use Use Carefully Not Use OK mild RD/USE, ↓ dose Use Use Carefully, ideally avoid Carefully, ideally avoid Use *This table was constructed based on the clinical experience and expert opinions of physicians who participated in the Consenus Panel (July 2007). IFG = impaired fasting glucose IGT = impaired glucose tolerance FBS = fasting blood sugar PPG = Postprandial glucose 44 MANAGED CARE / OCTOBER 2008
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