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uss) Making Treatment Decisions in Type 2 Diabetes BLOOD SUGARS MILDLY ELEVATED Trial of diet, exercise, and weightloss (if obese). If goals not reached, see below. NORMAL RENAL FUNCTION Nonobese Obese metformin thiazolidinediones Second-generation sulfonylureas onsulfonylurea secretagogues (if erratic meals) Elevated Fasting Blood Sugar metformin thiazolidinediones Second-generation sulfonylureas incretins Elevated Postprandial Blood Sugar nonsulfonylurea secretagogues e-Glucosidase inhibitors Second-generation sulfonylureas IMPAIRED RENAL FUNCTION Nonobese Obese Second-generation sulfonylureas nonsulfonylurea secretagogues (if erratic meals) thiazolidinediones «e-Glucosidase inhibitors thiazolidinediones sulfonylureas incretins Adapted from Dube D, Peiris AN: Concise update in management of diabetes, South Med J 95:4-9, 2002. Start at beginning dosages, and titrate every 2 to 4 weeks by monitoring preprandial and postprandial blood glucose; thiazolidinediones may take several weeks to reach maximum effectiveness; add second and third agents to achieve the goal of glycemic control. if poor contol is attained with three agents, or medical problems preclude the use of oral medications, consider insulin. Because diabetes is progressive, additional medications and higher dosages will be needed to maintain contrcl