If no contraindications are present always start with metformin as initial therapy in most patients with type 2 diabetes. However, consider insulin as first–line drug in patients presenting with A1c >10%, fasting sugar >250 mg/dL, random sugar consistently >300 mg/dL, or ketonuria.
Start with metformin at the time of diabetes diagnosis, along with lifestyle interventions. Titrate dose to its maximally effective dose (2000–2500 mg/day) over 1 to 2 months.
If situations predisposing to lactic acidosis are present, avoid metformin and consider a shorter–duration sulfonylurea.
Star with lifestyle intervention first, at the time of diagnosis. If lifestyle interventions have not produced a significant reduction in symptoms of hyperglycemia or in sugar levels after 1 or 2 weeks, add the first drug.
Those who cannot be given metformin or sulfonylureas, repaglinide is an alternative, particularly in a patient with chronic kidney disease at risk for hypoglycemia.
Other alternative is a pioglitazone, which may be considered in patients with lower initial A1c values or if there are specific contraindications to sulfonylureas. There is a concern about atherogenic lipid profiles and a potential increased risk for cardiovascular events with rosiglitazone.
One can consider sitagliptin as monotherapy for those intolerant of or have contraindications to metformin, sulfonylureas, or thiazolidinediones. It is a drug of choice as initial therapy in a patient with chronic kidney disease at risk for hypoglycemia. It is however, less potent than repaglinide, which can also be used safely in patients with chronic kidney disease.
In patients in whom it is difficult to distinguish type 1 from type 2 diabetes, start with insulin.
Further adjustments of therapy should be made every three months based on the A1C result aiming it close to the non diabetic range. If A1c values >7%, one need to further adjust the diabetic regimen.
If A1c remains >7% another drug should be added within 2 to 3 months of initiation of the lifestyle intervention and metformin.
To comment on this article, create a free account.
Sign Up to instantly get access to 10000+ Articles & 1000+ Cases
eMediNexus provides latest updates on medical news, medical case studies from India. In-depth medical case studies and research designed for doctors and healthcare professionals.
