Standards of Care Section 9 – Pharmacologic Approaches to Glycemic Treatment

Insulin Therapy for Type 1
This updated version of Meds Management includes more detailed information on insulin therapy for Type 1s. They note that the Diabetes Control and Complications Trial (DCCT) demonstrated that intensive therapy with multiple daily injections or insulin pump therapy reduced A1C and was associated with improved long-term outcomes. The study used short-acting and intermediate-acting human insulins. Since DCCT, rapid-acting and long-acting insulin analogs have been developed. These analogs are associated with less hypoglycemia, less weight gain, and lower A1C than human insulins in people with type 1 diabetes.

Type 2 Management Strategies – Pharmacologic Therapy of Type 2 Diabetes – 2019

Pharmacologic Approaches to Glycemic Treatment 2019.  This hyperglycemia road map details strategies to achieve glucose control for both Type 1 and Type 2 Diabetes. Section 9 of Standards of Care, January 2019.

Step 1 –

According to the ADA 2019 Standards, section 9, Metformin therapy should be started along with lifestyle management at diagnosis of type 2 Diabetes (unless contraindicated). Metformin is effective, safe, inexpensive and may reduce risk of CV events and death. If contraindicated, see figure 9.1 for alternatives.

Step 2

If A1c target is not achieved after 3 months, consider metformin and any one of the six preferred treatment options based on drug specific effects and patient factors. These factors include cardiovascular disease (ASCVD), congestive heart failure (CHF) or Chronic Kidney Disease (CKD). Plus, preventing hypoglycemia, weight gain and making sure medications are affordable.

If the patient has ASCVD, CHF or CKD, consider adding a second agent with evidence of cardiovascular risk reduction (based on drug specific effects and patient factors).

Medications indicated to improve CVD, CHF and CKD outcomes include:

• SGLT-2 Inhibitors – empagliflozin (Jardiance), canagliflozin (Invokana), dapagliflozin (Farxiga)
• GLP-1 Receptor Agonist – liraglutide (Victoza), semaglutide (Ozempic)

Step 3

If A1c target is still not achieved after 3 months, combine metformin plus two other agents for a three-drug combination. Drug choice should be based on avoidance of side effects such as hypoglycemia, weight gain, cost, and individual preference.

Step 4  

If A1c target is still not achieved after 3 months, add combination injectable therapy to the three-drug combination.

For all steps, consider including medications with evidence of CV risk reduction, based on drug specific effects and patient factors.

Medication Therapy Based on A1c

• Upon initial diagnosis of type 2, most can consider monotherapy
• If A1c is greater than or equal to 1.5% above target, consider dual therapy
• If A1c is greater or equal to 10%, or if BG 300 or more, or pt is markedly symptomatic (polyuria/polydipsia), consider insulin and injectable therapy.

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