All about Diabetes > Comprehensive Tutorial > Treatment Algorithms

Treatment algorithms:

Algorithm for the metabolic management Of Type 2 diabetes12

Tier 1: Well-validated core therapies


Algorithm for the metabolic management of type 2 diabetes. Reinforce lifestyle interventions at every visit. Check HbA1c every 3 months until HbA() is <7%, and then at least every 6 months. The interventions should be changed if HbA1c is >7%. () Sulfonylureas other than glybenciamide (glyburide) or chlorpropamide. Insufficient clinical use to be confident regarding safety. See text box: Titration of metformin. See Fig. 1 for initataion and adjustment of insulin, CHF, congestive heart failure.

12 Diabetologia (2009) 52:17-30

Initiation and adjustment of insulin regimens12

If hypoglycaemia occurs, or fasting glucose level <3.9 mmol/l (70 mg/dl), reduce bedtime dose by 4 units or 10% whichever is greater.

Initation and adjustment of insulin regiments. Insulin regimens should be designed taking lifestyle and meal schedule into account. The algorithm can only provide basic guidelines for initiation and adjustment of insulin. See reference 90 for more detailed instructions. "Pre-mixed" insulins not recommended during adjustment of doses; however, they can be used conveniently, usually before breakfast and/or dinner, if proportion of rapid and intermediate-acting insulins is similar to the fixed proportions available. bg, blood glucose.

12 Diabetologia (2009) 52:17-30

Summary of glucose-lowering interventions


Expected decrease in HbA1c (%) with monotherapy



Tier 1: well-validated core
Step 1: initial therapy
Lifestyle to decrease weight and increase activity

1.0 - 2.0

Broad benefits

Insufficient for most within first year


1.0 - 2.0

Weight neutral

Gl side effects, contraindicated with renal insufficiency

Step 2: additional therapy insulin

1.5 - 3.5

No dose limit, rapidly effective, improved lipid profile

One to four injections daily, monitoring weight gain, hypoglycaemia, analogues are expensive.



Rapidly effective

Weight gain, hypoglycaemia (especially with glibenclamide or chlorpropamide)

Tier 2: less well-validated Thiazolidinedione


Improved lipid profile (pioglitazone), potential decrease in MI (pioglitazone)

Fluid retention, CHF, weight gain, bone fracture, expensive, potential increase in MI (rosiglitazone)

GLP-1 agonist


Weight loss

Two injections daily, frequent Gl side effects, long term safety not established expensive

Other therapy α-Glucosidase inhibitor


Weight neutral

Frequent Gl side effects, three times/day dosing, expensive



Rapidly effective

Weight gain, three times/day dosing hypoglycaemia, expesive



Weight loss

Three injections daily, frequent Gl side effects, longterm safety not established, expensive

DPP-4 inhibitor


Weight neutral

Long-term safety not established expensive

Repaglinide more effective in lowering HbA1c than nateglinide
CHF - congestive heart failure; Gl - gastrointestinal; Ml - myocardial infarction


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