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GLYCEMIC CONTROL ALGORITHM FOR TYPE 2 DIABETES MELLITUS

IN CHILDREN1 AND ADULTS


UHS Recommended 1 Line Agent
st

1, 2

Metformin

Targets
A1C 7%
Fasting SMBG 100 mg/dL
2-hr PPSMBG 140-180 P g/G

Initial Intervention
Diabetes Education, Medical
Nutrition and Exercise

Targets Met

Fasting SMBG/PP Targets


Not Met After 1 Month

A1C every 3-6 months


Mono-therapy

Begin Monotherapy or
Dual Therapy

Dual Therapy

Targets Met
Monotherapy

Continue Therapy
A1C every 3-6 months

Targets Not Met After 3 Months

Alternative Monotherapy Options3


TZDs
Sulfonylureas
GLP-1 receptor agonists4

Second-line Pharmacotherapy Options


Sulfonylurea + metformin
Metformin +TZD
Sulfonylurea or metformin + GLP-1 receptor
agonist
TZD +GLP-1 receptor agonist
Sitagliptin5 + metformin or + TZD
Insulin6

Begin Dual Therapy

Targets Met
Continue Therapy
A1C every 3-6 months

Definitions:
TZD= Thiazolidinedione (Pioglitazone)
SMBG= Self-Monitored Blood Glucose
PP= Postprandial
GLP-1=Glucagon-Like Peptide-1

Targets Not Met After 3 Months


Add 3rd oral agent or GLP-1 receptor agonist if A1C < 8.5%;
OR
Add insulin for A1C > target (See Insulin Algorithm);
Consider a referral to endocrinologist

Metformin is the only FDA-approved oral diabetic agent in children


Preferred if obese or dyslipidemic
3
First line if there is a contraindication or intolerance to metformin or at the discretion of Endocrinology
4
Exenatide and Liraglutide restricted to Faculty Physicians for FDA approved indications and to Endocrinology for use at
physicians discretion
5
Only available if a patient has failed metformin or TZD or if a patient has a contraindication to metformin or TZD
6
If initial presentation with fasting glucose > 260 mg/dl in a symptomatic patient, consider insulin as initial intervention.
*If HbA1C > 9%, consider starting with step 3.
2

BK 4/4/07
RG 5/8/09
CAG 3/1/11

(unless contraindicated)