Summary
- This section describes the tiers of treatment in diabetes
- However, take this as a general approach.
- In reality, treatment rarely follows the rigidity of the guidelines and is more dependent on the suitability of medications for the patient
- This image from the BMJ summarises the management in one image
The Hierarchy Of T2DM Treatment
- Treat conservatively with no diabetic medication if Hba1c >6.5%
- Use only this for ≥6 weeks and then reassess
- Monotherapy – use metformin if still >6.5% after ≥6 weeks with conservative treatment
- Add a 2nd line drug if still ≥7.5% after another ≥6 months
- The drugs are usually used in the following order:
- DPP4 inhibitors (-gliptins)
- SGLT2 inhibitors – especially if weight and cardiovascular control is key
- Sulphonylurea
- Traditionally used as 2nd line but is often not suitable/well-tolerated in patients therefore is now less common
- Sulphonylurea receptor binders are used if the patient has a very irregular lifestyle (very rare)
- Pioglitazone
- Useful if very insulin resistant or in South Asians
- Add a 3rd line drug if >7.5% after another 9 months on dual therapy
- Usually add one of the options above or one of the following
- Insulin is usually added in T2DM after ≥2 drugs have already been tried
- Must involve a trained diabetic nurse at this point
- Can be used with sulphonylureas but review if hypoglycaemia occurs
- Discontinue SRBs, exenatide, gliptins, pioglitazone, or liraglutide before starting insulin
- Do not use if obese – see below
- GLP1 analogues (exenatide) – increase insulin release and are added here
- Useful if patient is overweight(>35kg/m2) or otherwise unable to use insulin
- If triple therapy is not working the patient is likely to be insulin resistant:
- Start insulin if not already used
- Consider pioglitazone if not already added