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New Treatment Algorithm for the Treatment of Type 2 Diabetes

The American Association of Clinical Endocrinologists (AACE) recently created an algorithm for the treatment of Type 2 Diabetes Mellitus. The goal is to achieve glycemic control by targeting a blood glucose level (A1C) of 6.5 percent through lifestyle modifications such as diet and exercise, in combination with drug therapy.

  1. One to Two Drug Therapy for A1C 6.5 Percent to 7.5 Percent

    • Patients with A1C levels of 6.5 percent to 7.5 percent should be started on monotherapy with metformin as a cornerstone drug, or pioglitazone, sitagliptin or acarbose if kidney or liver problems exist. If monotherapy fails, exenatide, sitagliptin or glyburide should be added.

    Three Drug to Insulin Therapy for A1C 6.5 Percent to 7.5 Percent

    • If dual therapy with the above medications at the maximum effective dose fails to achieve glycemic control, metformin can be combined with sitagliptin or exenatide, plus either glyburide, pioglitazone or glinide. If the insulin secreting ability of the pancreas combined with triple drug therapy fails to achieve glycemic control, then insulin therapy is needed and metformin remains the safest medication to combine with insulin therapy.

    Two Drug Therapy for A1C 7.6 Percent to 9.0 Percent

    • Monotherapy is unlikely to achieve an A1C level of 6.5 percent in patients with current A1C levels of 7.6 percent to 9.0 percent. Therefore, dual therapy should be instituted with metformin plus either exenatide, sitagliptin, pioglitazone, glyburide or glinide.

    Three Drug to Insulin Therapy for A1C 7.6 Percent to 9.0 Percent

    • If dual therapy does not achieve glycemic control, a third drug should be added. AACE recommends using either metformin with sitagliptin plus pioglitazone or glyburide, metformin with exenatide plus pioglitazone or glyburide, or metformin with pioglitazone plus glyburide. If insulin therapy is needed to reach A1C targets, then metformin remains the safest drug to use in conjunction with insulin.

    Managing A1C over 9.0 Percent

    • In newly diagnosed, asymptomatic diabetes patients, dual therapy or triple therapy with the above mentioned medications may be used in conjunction with metformin to achieve a reduction in A1C. In newly diagnosed patients with symptoms of frequent urination, excessive thirst or weight loss, or in patients already under drug treatment but still experiencing A1C levels over 9.0 percent, insulin therapy should be started immediately.

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