Treatment Algorithm for Type 2 Diabetes
If any of the following occur skip Steps 1 through 3 and go directly to Step 4: FPG >250, glucose >300, A1C >10%, active liver disease, ETOH abuse, ketonuria, or weight loss. If acidotic, patient should be hospitalized.
Step 1: Start with metformin and lifestyle interventions.
Step 2: If target levels are not reached with Step 1, add a sulfonylurea.
Step 3: If target levels are not reached with Step 2, add either basal insulin or a thiazolidinedione (TZD). To start basal insulin, consider 10 units of NPH at bedtime or 10 units of a long-acting insulin.
Step 4: If targets are not reached with Step 3, start/intensify insulin therapy.
Pneumococcal vaccine – at diabetes dx; revaccinate once after age 65 if more than 5 years since the first shot
Td /Tdap – per protocol or routine
PPD – once after diagnosis of diabetes; a positive reaction in patient with diabetes is ≥10 mm
Don’t forget the following:
Glucose toxicity – insulin production is decreased with prolonged hyperglycemia; treating with insulin short-term helps reverse this condition.
Pancreatic exhaustion – almost all individuals with type 2 diabetes will eventually require insulin.
ADA. Summary: Standards of Medical Care in Diabetes.
Diabetes Care 2011; 34(Sup 1): S4–S7.
Nathan, DM. et. al. Medical Management of Hyperglycemia in Type 2 Diabetes: A Consensus Algorithm for the Initiation and Adjustment of Therapy.
Diabetes Care 2009; 32:193–203.