Cardiovascular Disease and Risk Management–2020. For example, instruction of patients in self-titration of insulin doses based on self-monitoring of blood glucose improves glycemic control in patients with type 2 diabetes initiating insulin (58). The Diabetes Control and Complications Trial (DCCT) demonstrated that intensive therapy with multiple daily injections or continuous subcutaneous insulin infusion (CSII) reduced A1C and was associated with improved long-term outcomes (1–3). E. The American Diabetes Association/European Association for the Study of Diabetes consensus report “Management of Hyperglycemia in Type 2 Diabetes, 2018” and the 2019 update (33,34) recommend a patient-centered approach to choosing appropriate pharmacologic treatment of blood glucose (Fig. Diabetes Care. doi: 10.2337/dc18-S008. Insulin initiation and titration can be challenging for many primary care providers who are involved in the treatment of patients with type 2 diabetes. A recent randomized trial confirmed previous observations that metformin use is associated with vitamin B12 deficiency and worsening of symptoms of neuropathy (38). People with type 2 diabetes are generally more insulin resistant than those with type 1 diabetes, require higher daily doses (∼1 unit/kg), and have lower rates of hypoglycemia (77). Management of hyperglycaemia in type 2 diabetes, 2018. In patients with contraindications or intolerance to metformin, initial therapy should be based on patient factors; consider a drug from another class depicted in Fig. Ann Intern Med. | Risk for IM insulin delivery is increased in younger, leaner patients when injecting into the limbs rather than truncal sites (abdomen and buttocks) and when using longer needles. Methods: More recently, two new insulin formulations with enhanced rapid action profiles have been introduced. At the time of a diagnosis of type 2 diabetes, the ADA recommends prompt initiation of lifestyle management, determination of appropriate glycemic targets (inclusive of A1C goals), and initiation of pharmacologic therapy ().Figure 1 provides a summary of general recommendations from the ADA’s Standards of Medical Care in … Description: U-300 glargine has a longer duration of action than U-100 glargine but modestly lower efficacy per unit administered (81,82). Educating and involving patients in insulin management is beneficial. ©2019 by the American Diabetes Association. Members of the [ADA Professional Practice Committee][1], a multidisciplinary expert … However, the occurrence of this complication is now known to be very rare, and metformin may be safely used in patients with reduced estimated glomerular filtration rates (eGFR); the FDA has revised the label for metformin to reflect its safety in patients with eGFR ≥30 mL/min/1.73 m2 (37). Results of recent large trials with cardiovascular and renal outcomes are emphasized. The committee selected and reviewed the studies, developed the recommendations, and solicited feedback from the larger clinical community. In addition to hyperglycemia, insulinopenia can contribute to other metabolic disturbances like hypertriglyceridemia and ketoacidosis as well as tissue catabolism that can be life threatening. Adapted from Davies et al. A, 9.6 Early combination therapy can be considered in some patients at treatment initiation to extend the time to treatment failure. Postprandial glucose excursions are best controlled by a well-timed injection of prandial insulin. National Center for Biotechnology Information, Unable to load your collection due to an error, Unable to load your delegates due to an error. In addition, new longer-acting basal analogs (U-300 glargine or degludec) may confer a lower hypoglycemia risk compared with U-100 glargine in patients with type 1 diabetes (9,10). Chamberlain JJ, Doyle-Delgado K, Peterson L, Skolnik N. Ann Intern Med. Thus, a practical extension of these results to clinical practice is to use these drugs preferentially in patients with type 2 diabetes and established ASCVD or indicators of high ASCVD risk. Pharmacologic Approaches to Glycemic Treatment. Recommendations: Reduction of nocturnal hypoglycemia in people with type 1 diabetes using insulin pumps with glucose sensors is improved by automatic suspension of insulin delivery at a preset glucose level (12–14). CLASSIFICATION AND DIAGNOSIS OF DIABETES. 2017 Apr 18;166(8):572-578. doi: 10.7326/M16-2937. The principal side effects of metformin are gastrointestinal intolerance due to bloating, abdominal discomfort, and diarrhea; these can be mitigated by gradual dose titration. In trials comparing the addition of an injectable GLP-1 RAs or insulin in patients needing further glucose lowering, the efficacy of the two treatments was similar (50–52). USA.gov. Basal insulin alone is the most convenient initial insulin regimen and can be added to metformin and other oral agents. The FDA has also approved a concentrated formulation of rapid-acting insulin lispro, U-200 (200 units/mL). In addition, recent evidence supports the utility of GLP-1 RAs in patients not reaching glycemic targets with use of non-GLP-1 RA oral agent regimens. For these patients, incorporating one of the SGLT2 inhibitors or GLP-1 RAs that have been demonstrated to have cardiovascular disease benefit is recommended (Table 9.1). Inhaled human insulin has a rapid peak and shortened duration of action compared with RAA and may cause less hypoglycemia and weight gain (7), and faster-acting insulin aspart may reduce prandial excursions better than RAA (8); further investigation is needed to establish a clear place for these agents in diabetes management. 9. See page S101. Injection site rotation is additionally necessary to avoid lipohypertrophy, an accumulation of subcutaneous fat in response to the adipogenic actions of insulin at a site of multiple injections. If the A1C target is not achieved after approximately 3 months, metformin can be combined with any one of the preferred six treatment options: sulfonylurea, thiazolidinedione, DPP-4 inhibitor, SGLT2 inhibitor, GLP-1 RA, or basal insulin; the choice of which agent to add is based on drug-specific effects and patient factors (Fig. When A1C is ≥1.5% (12.5 mmol/mol) above the glycemic target (see Section 6 “Glycemic Targets,” https://doi.org/10.2337/dc20-S006, for selecting appropriate targets), many patients will require dual combination therapy to achieve their target A1C level (40).