IDC Treatment of Type 2 Diabetes: Glycemic Control

Glycemic Targets

A1C<7%*, Pre-meal glucose 70-120 mg/dL, and 2 hour Post-meal glucose <160 mg/dL

At presentation

Self-management

Refer for diabetes education

Monitor glucose, food and activity; titrate medications1

Nutrition and activity

Refer to registered dietitian for MNT

Lowers A1C 1-2 %

Advance if not at target

A1C 7-8.9%
FPG 150-200
RPG 200-300
A1C 9-11%
FPG 201-300
RPG 301-350

Emotional health

Psychosocial support/motivation
Assess for anxiety or depression

Metformin2
Titrate to clinically effective dose

Advance if not at target in 3 months

Two-drug therapy
Metformin +
DPP-4 I

Metformin +
Sulfonylurea

Metformin +
GLP-1 Mimetic

Metformin +
Pioglitazone3

Weight: Modest gain

Hypoglycemia: Yes
Cost: $

Weight: Neutral
Hypoglycemia: No
Cost: $$$

Weight: Loss
Hypoglycemia: No
Cost: $$$$

Weight: Gain
Hypoglycemia: No
Cost: $$$

Greatest A1C lowering,

works quickly

Few known side effects

Injectable, GI side effects

Treats insulin resistance;

known side effects4

Titrate to

Advance if

clinically effective dose

not at target in 3 months

Three-drug therapy
5

Met + SU + LA

NPH if cost is an issue

A1C >11%7
FPG >300
RPG >350

Met + DPP-4 I + LA6

Titrate to clinically effective dose

Met + Pio + GLP-1 M

Met + Pio + SU

Advance if not at target in 3 months

Insulin therapy (2 or more injections)

+Sensitizer(s)

2007 International Diabetes Center at Park Nicollet All rights reserved and protected.

Eliminate all sweetened

beverages
Minimum 3 meals/day
Approximately 3 carb
choices (45 g)/meal12

Physical activity
(150 minutes/week)
Modest weight loss
(5-7%)

Refer to psychologist or
social worker if
persistently elevated
A1C

Met +Pio + DPP-4 I

Met + GLP-1 M + LA6

Background
+ Mealtime Insulin 8,9
RA RA RA LA5

Consistent
carbohydrate

Premixed Insulin8

Mix 70/30 0 - Mix 70/30 010

Mix 75/25 0 - Mix 75/25 010
70/30 0 - 70/30 011

+ Sensitizer(s)

For insulin therapy

Background:
Consistent carb
Background and
mealtime:
Insulin-to-carb ratio or
consistent carb
Premixed: Consistent
meal timing and carb

IDC Treatment of Type 2 Diabetes: Glycemic

Control Abbreviations and Footnotes
*Less stringent A1C goals are appropriate for some individuals (those with repeated severe hypoglycemia or
hypoglycemia unawareness, frail elderly, children, and, based on preliminary ACCORD trial findings, those at high
risk for CVD).

Abbreviations
DPP-4 I, dipeptidyl peptidase-4 inhibitor (sitagliptin); GLP-1 M glucagon like peptide-1 mimetic (exenatide); LA,
long-acting insulin (glargine, detemir); Met, metformin; MNT, Medical Nutrition Therapy, NPH, intermediate-acting
insulin; Pio, pioglitazone; RA, rapid-acting insulin (aspart, lispro, glulisine); RPG, random plasma glucose in mg/dL;
SU, sulfonylurea

Footnotes
1. Based on SMBG food and activity record; consider continuous glucose monitoring (CGM); 2. Check liver and
renal function; 3. Pioglitazone preferred due to possible CV risk with rosiglitazone; 4. CHF, edema, weight gain,
bone fractures; 5. One daily injection (any consistent time); may benefit from bid dosing; 6. The combination of
DPP-4 I or exenatide with insulin is not FDA approved; 7. If clinically stable and consuming excessive sweetened
beverages start orals & re-evaluate need for insulin in 1-2 weeks; 8. Pramlintide may be added to mealtime
insulin; 9. Most physiological and flexible regimen; 10. Pre-mixed rapid-acting and rapid-acting + protamine
suspension; 11. Pre-mixed NPH and regular human insulin; 12. For glucose control: 3-4 carbs/meal and for glucose
control and weight loss: 2-3 carbs/meal.

2007 International Diabetes Center at Park Nicollet All rights reserved and protected.