What are the ADA guidelines on the pharmacologic means of glycemic therapy in type 2 diabetes mellitus (DM)?

Updated: Sep 27, 2021
  • Author: Romesh Khardori, MD, PhD, FACP; Chief Editor: George T Griffing, MD  more...
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Answer

In September 2020, the ADA published clinical guidelines on pharmacologic means of glycemic therapy in type 2 diabetes. They include the following:

  • Metformin therapy is the preferred initial pharmacologic treatment for type 2 diabetes
  • To extend the time to treatment failure, early combination therapy can, in some patients, be considered at treatment initiation
  • If evidence of ongoing catabolism exists (weight loss), if symptoms of hyperglycemia are present, or when HbA1c or blood glucose levels are very high (HbA1c >10% [86 mmol/mol], blood glucose ≥16.7 mmol/L [300 mg/dL]), consider early introduction of insulin
  • Employ a patient-centered approach to guide the choice of pharmacologic agents, with factors such as  cardiovascular comorbid conditions, hypoglycemia risk, impact on weight, cost, risk for side effects, and patient preferences taken into account
  • It is recommended that a sodium-glucose cotransporter–2 (SGLT2) inhibitor or glucagonlike peptide-1 receptor agonist (GLP-1 RA) with demonstrated cardiovascular disease benefit be administered to patients with type 2 diabetes who have established atherosclerotic cardiovascular disease (ASCVD), indicators of high ASCVD risk, established kidney disease, or heart failure
  • The use of GLP-1 RAs, when possible, is preferred over insulin therapy in the treatment of patients with type 2 diabetes who need greater glucose reduction than oral agents can provide
  • Reevaluate the patient’s medication regimen and medication-taking behavior every 3 to 6 months, adjusting them as needed to incorporate specific factors that affect treatment choice

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