APPENDIX 2.

MANAGEMENT OF HYPERGLYCEMIA IN TYPE 2 DIABETES

Clinical Assessment
Lifestyle intervention (initiation of nutrition therapy and physical activity)

L A1C > 0.07 but < 0.09

after trial with lifestyle changes
A1C 0.09 Symptomatic hyperglycemia with metabolic
decompensation (e.g., diabetic ketoacidosis)

Initiate pharmacotherapy immediately without

Initiate waiting for effect from lifestyle interventions. Initiate insulin
I metformin Consider adding metformin concurrently
with another agent from a different class; or
metformin

Initiate insulin

F If not at target

Add an agent best suited to the individual based on

advantages/disadvantages listed below and information in Appendix 1.

E Class Expected in
A1C
Hypo-
glycemia
Advantages Disadvantages

Alpha-glucosidase Rare Improved postprandial control GI side effects

inhibitor Weight neutral
Incretin agent: to Rare Improved postprandial control Newer agent so long term
S DPP-4 inhibitor Weight neutral safety is unknown
Insulin Yes No dose ceiling, many types, Weight gain
flexible regimens
Insulin Improved postprandial control Requires TID to QID dosing,

T secretagogue:
Meglitinide to Yes*
Newer sulfonylureas (glicazide,
glimepiride) associated with less
weight gain

Sulfonylurea Yes hypoglycemia than glyburide

Requires 6 12 weeks for

Thiazolidinedione Rare Durable monotherapy maximal effect, weight gain,
Y edema, rare CHF, rare
fractures in women
GI side effects (orlistat)
Weight loss agent None Weight loss

L If not at target

Add another drug from a different class; or

E Add bedtime basal insulin to other agent(s); or

Intensify insulin regimen

Make timely adjustments to and/or add antihyperglycemic agents to attain target A1C within 6 to 12 months

: <0.01 reduction; : 0.01-0.02 reduction; : >0.02 reduction

DPP-4: Dipeptidyl peptidase-4
* Less hypoglycemia in context of missed meals

See Info Point 19 for updated information

Adapted and Reprinted with Permission from: Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian
Diabetes Association 2008 clinical practice guidelines for the prevention and management of diabetes in Canada. Pharmacologic Management
of Type 2 Diabetes. Can J Diabetes, 32 (suppl 1): S56.

The Foundation for Medical Practice Education, www.fmpe.org

August 2009

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