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Diagnosis and Management of Type 2 Diabetes, 10th Edition, Ch 12-Pt 1

Treatment Algorithm


Steve V. Edelman, MD

Robert R. Henry, MD

The primary treatment goals of managing Type 2 diabetes are to:

• Eliminate symptoms of hyperglycemia

• Recognize the symptoms of hypoglycemia….

• Achieve and maintain normal or near-normal metabolic and biochemical parameters (both fasting and postprandial blood glucose levels, A1C [Table 12.1], LDL and HDL cholesterol, and fasting triglycerides)

• Achieve normal blood pressure and address procoagulant state

• Reduce insulin resistance and its adverse metabolic consequences

• Assist the patient in achieving and maintaining a reasonable body weight

• Prevent or delay the development and progression of microvascular and macrovascular complications

Therapeutic efforts to achieve these goals involve using a variety of treatment modalities:

• Dietary modifications

• Regular physical activity

• Aspirin therapy

• Antidiabetic agents

• Insulin injections.

An individualized approach is recommended based on:

• Patient age

• The presence of coexisting illnesses and/or diabetes-related complications

• Lifestyle, including:

– Attitude
– Habits
– Cultural/ethnic status

• Financial considerations

• Ability to learn and follow self-management skills

• Level of patient motivation.

The cornerstone of effective diabetes management is maintaining good glycemic control. Compelling evidence indicates that long-term glycemic control can prevent or delay the microvascular complications of diabetes.

The DCCT and the UKPDS demonstrated definitively the value of improved glycemic therapy in patients with Type 1 and Type 2 diabetes in delaying the onset and slowing the progression of retinopathy, nephropathy, and neuropathy.

The benefits of reducing glycemia are seen in both Type 1 and Type 2 diabetes. The ADA now recommends establishing a management goal of achieving the best possible blood glucose control in patients with Type 2 diabetes. Treatment methods for managing Type 2 diabetes should focus on:

• Dietary modifications

• Exercise

• Weight control

• Supplemental oral hypoglycemic agents and/or insulin as needed.

The following algorithm (Figure 12.1) provides a general guideline for making decisions regarding the various types of pharmacologic therapy. It should be noted that several consensus algorithms proposed by various organizations such as the ADA, the EASD, the AACE, and the Texas Diabetes Council differ somewhat in their details including glycemic targets and the sequential use of specific medications. For example, the target glycemic goal proposed by the AACE is an A1C of 6.5% whereas a goal of A1C


Next Week, Assessment of the Treatment Regimen

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