Type 2 Diabetes Treatment Algorithm
Initial Treatment Approach
- The American Diabetes Association recommends metformin as first-line therapy for type 2 diabetes, concurrently with lifestyle modifications including nutrition and physical activity 1
- For newly diagnosed patients who are overweight or obese, lifestyle modifications including physical activity and counseling to lose at least 5% of body weight should be initiated 2
- Metformin should be started at or soon after diagnosis if not contraindicated, at a low dose of 500 mg daily, increasing by 500 mg every 1-2 weeks, up to an ideal maximum dose of 2000 mg daily in divided doses 2, 3
Special Circumstances Requiring Insulin First
- Insulin therapy should be initiated instead of metformin as first-line treatment in patients with ketosis or diabetic ketoacidosis, random blood glucose ≥250 mg/dL, HbA1c >9% (>75 mmol/mol), severe hyperglycemia with catabolism, or symptomatic diabetes with polyuria, polydipsia, and weight loss 1, 4, 5
Treatment Intensification Algorithm
- When initial therapy is insufficient, a second agent should be added to metformin, with selection based on patient factors, disease characteristics, drug properties, and patient preferences 2
- Other second-line options include sulfonylureas, thiazolidinediones, and DPP-4 inhibitors 2
Insulin Therapy
- Insulin therapy should be considered when triple therapy fails to achieve glycemic targets, starting with basal insulin (typically 0.5 units/kg/day) and titrating every 2-3 days based on blood glucose monitoring 5, 6
- If glycemic targets are still not met with escalating doses of basal insulin, prandial insulin should be added 5
Monitoring and Follow-up
- HbA1c should be monitored every 3 months until target is reached, then at least twice yearly, with therapy adjusted when targets are not met 2
- Continuous glucose monitoring should be considered for patients requiring frequent blood glucose monitoring 5