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Mendez How To Use The Type 2 Diabetes Treatment Algorithm PDF
Mendez How To Use The Type 2 Diabetes Treatment Algorithm PDF
Treatment Algorithm
Carlos Mendez, MD, FACP
1. Patient-centered care
2. Anti-hyperglycemic therapy
3. Implementation strategies
4. Other considerations
Learning Objectives
• Recognize drug-specific and patient factors of
antihyperglycemic agents to support patient-
provider shared decision making
• Demonstrate when and how to intensify therapy
• Identify opportunities to refer patients to
Diabetes Self-Management Education
Impact of Intensive Therapy for Diabetes:
Summary of Major Clinical Trials
Study Microvasc CVD Mortality
UKPDS
DCCT / EDIC*
ACCORD
ADVANCE
VADT
Kendall DM, Bergenstal RM. © International Diabetes Center 2009 * in T1DM Initial Trial
UK Prospective Diabetes Study (UKPDS) Group. Lancet 1998;352:854.
Holman RR et al. N Engl J Med. 2008;359:1577. DCCT Research Group. N Engl J Med 1993;329;977.
Nathan DM et al. N Engl J Med. 2005;353:2643. Gerstein HC et al. N Engl J Med. 2008;358:2545. Long Term Follow-up
Patel A et al. N Engl J Med 2008;358:2560. Duckworth W et al. N Engl J Med 2009;360:129. (erratum:
Moritz T. N Engl J Med 2009;361:1024) . Writing Group for the DCCT/EDIC Research Group. JAMA. 2015;313(1):45-53.
SGLT-2
inhibitors
Patient-Centered Approach
“...providing care that is respectful of and responsive
to individual patient preferences, needs, and values -
ensuring that patient values guide all clinical
decisions.”
A1C
• <7.0%*
Preprandial capillary plasma glucose
• 80–130 mg/dL*
(4.4–7.2 mmol/L)
Disease Duration
Relevant Comorbidities
Lifestyle Management
Metformin
Efficacy High
Hypoglycemia No
Neutral (Potential for
Weight Change
Modest Loss)
Cost Low
Oral/SQ Oral
SGLT-2 Inhibitors
Compounds: Canagliflozin; Dapagliflozin; Empagliflozin
Efficacy Intermediate
Hypoglycemia No
Cost High
Oral/SQ Oral
SGLT-2 Inhibitors
Efficacy High
Hypoglycemia No
Cost High
Oral/SQ SQ
GPL-1RAs
ASCVD Neutral: lixsenatide, exenatide
extended release
CV Effects Benefit: liraglutide
CHF Neutral
DPP-4 Inhibitors
Compounds: Sitagliptin; Saxagliptin; Linagliptin; Alogliptin
Efficacy Intermediate
Hypoglycemia No
Cost High
Oral/SQ Oral
Thiazolidinediones
Compounds: Pioglitazone; Rosiglitazone
Efficacy High
Hypoglycemia No
Cost Low
Oral/SQ Oral
Thiazolidinediones
Efficacy High
Hypoglycemia Yes
Cost Low
Oral/SQ Oral
Efficacy Highest
Hypoglycemia Yes
Insulin
ASCVD Neutral
CV Effects
CHF Neutral
American Diabetes Association. 8. Pharmacologic approaches to glycemic treatment: Standards of Medical Care in Diabetes. Diabetes
Care 2018; 41 (Suppl. 1): S73-S85
Weight
Comorbidities
• Coronary artery disease • Liver dysfunction
• Heart Failure • Hypoglycemia-prone
• Chronic kidney disease
Identifying and addressing barriers to medication adherence
• Cost
• Side effects
Pre-mixed Pre-mixed
formulations formulations
Short (Regular)
Long (Detemir)
(Degludec)
Long (Glargine)
0 2 4 6 8 10 12 14 16 18 20 22 24
Hours After Injection
Approach to Starting and Adjusting Insulin in T2DM
A. Fasting
B. Preprandial
C. Postprandial
D. Nocturnal
E. B and C above
Key Points
Individualize glycemic targets & BG-lowering therapies
Lifestyle foundation of any T2DM therapy program
Unless contraindicated, metformin is optimal first-line drug
• In patients with ASCVD and T2D, subsequent treatment
should incorporate agent proven to ↓ CV events and/or CV
mortality
• Ultimately, many patients will require insulin therapy alone
or in combination with other agents to maintain BG control
• Shared decision making (focus on his/her preferences,
needs & values)