MD Conference Express - ENDO 2015 - (Page 7)

Figure 1. General Recommendations for Antihyperglycemic Therapy, T2DM Healthy eating, weight control, increased physical activity, and diabetes education Monotherapy Metformin Efﬁcacy........................................................................................................................ high......................................................................................................................... Hypo risk..................................................................................................................... low risk.................................................................................................................... Weight......................................................................................................................... neutral / loss............................................................................................................ Side effects................................................................................................................. GI / lactic acidosis.................................................................................................... Costs........................................................................................................................... low........................................................................................................................... If HbA1c target not achieved after ~3 months of monotherapy, proceed to 2-drug combination (order not meant to denote any speciﬁc preference-choice dependent on a variety of patient- and disease-speciﬁc factors): Metformin Metformin Metformin Metformin Metformin Metformin + + + + + + SGLT2 GLP-1 receptor Insulin (basal) ThiazolidineSulfonylurea DPP-4 inhibitor agonist dione inhibitor Dual therapy† Efﬁcacy..................... high............................... high .............................. intermediate ................ intermediate ................. high .............................. highest ................... Hypo risk.................. moderate risk................. low risk ........................ low risk ........................ low risk ........................ low risk ........................ high risk ................. Weight...................... gain............................... gain .............................. neutral ......................... loss .............................. loss............................... gain ........................ Side effects.............. hypoglycemia................. edema, HF, fxs .............. rare ............................. GU, dehydration ............ GI ................................. hypoglycemia ......... Costs........................ low................................. low ............................... high ............................. high ............................. high .............................. variable .................. If HbA1c target not achieved after ~3 months of dual therapy, proceed to 3-drug combination (order not meant to denote any speciﬁc preference-choice dependent on a variety of patient- and disease-speciﬁc factors): Metformin + Triple therapy Metformin + Sulfonylurea + Thiazolidinedione + SU TZD Metformin + DPP-4 inhibitor + Metformin + SGLT2 inhibitor + SU SU Metformin + GLP-1 receptor agonist + SU or DPP-4-i or DPP-4-i or TZD or TZD or TZD or or Insulin or SGLT2-i or SGLT2-i or DPP-4-i GLP-1-RA or GLP-1-RA or Insulin or Insulin or TZD or DPP-4-i or SGLT2-i or Insulin or Combination injectable therapy‡ SGLT2-i or Metformin + Insulin (basal) + GLP-1-RA Insulin § § § § § If HbA1c target not achieved after ~3 months of triple therapy and patient (1) on oral combination, move to injectables; (2) on GLP-1-RA, add basal Insulin; or (3) on optimally titrated basal Insulin, add GLP-1-RA or mealtime Insulin. In refractory patients consider adding TZD or SGLT2-I: Metformin + Basal insulin + Mealtime insulin or GLP-1-RA GLP-1 RA, glucagon-like peptide 1 receptor agonist; HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol; SGLT2i, sodium-glucose cotransporter-2 inhibitor; SU, sulfonylurea; T2DM, type 2 diabetes mellitus; TZD, thiazolidinedione. †Consider initial therapy at this stage when HbA1c is 9% (75 mmol/mol). ‡Consider initial therapy at this stage when blood glucose is 300-350 mg/dL (16.7-19.4 mmol/L) and/or HbA 1c 10-12% (86-108 mmol/mol), especially if patient is symptomatic or if catabolic features (weight loss, ketosis) are present, in which case basal insulin 1 mealtime insulin is the preferred initial regimen. §Usually a basal insulin (eg, NPH, glargine, detemir, degludec). Reproduced from Inzucchi SE et al. Management of Hyperglycemia in Type 2 Diabetes 2015: A Patient Centered Approach, Diabetes, 38, 2015, Copyright and all rights reserved. Material from this publication has been used with the permission of American Diabetes Association. Official Peer-Reviewed Highlights From ENDO 2015 7

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MD Conference Express - ENDO 2015