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Table 4 Algorithm for the treatment of type 2 diabetes - 2009 update -

From: Algorithm for the treatment of type 2 diabetes: a position statement of Brazilian Diabetes Society

STAGE 1: INITIAL CONDUCT ACCORDING TO CURRENT CLINICAL CONDITION
Mild manifestations Moderate manifestations Severe manifestations Hospitalization if glycemic levels >300 mg/dL
• Glycemic levels <200 mg/dL
+
• Mild symptoms or no symptoms
+
• Absence of other acute concomitant diseases
• Any glycemic levels between 200-300 mg/dL
+
• Absence of criteria for mild or severe manifestations
• Any glycemic levels above 300 mg/dL
= Or =
• Significant weight loss
= Or =
• Severe and significant symptoms
= Or =
• Presence of ketonuria
Under the following conditions:
• Diabetic ketoacidosis and hyperosmolar state
= Or =
• Intercurrent severe disease or comorbidity
Metformin (500 mg/day, intensifying up to 2,000 mg/day) + lifestyle changes.
If patient does not reach A1C<7%
in 4-6 weeks →
Note: In case of metformin intolerance, prolonged action formulations may be useful. If the problem persists, choose one of the options in Step 2
Metformin (500 mg/day, intensifying up to
2,000 mg/day) +
lifestyle changes + other oral antidiabetic drugs
CRITERIA FOR INCLUDING SECOND OAD
Start insulin therapy immediately Start therapy according to the algorithm recommendations and to glycemic control obtained after discharge from hospital
STAGE 2: ADD OR MODIFY SECOND AGENT ACCORDING TO A1C LEVEL(*)
7- 8% 8-10% >10%  
Sulphonylurea
DPP-4 inhibitors
Glitazone
Glinides (prevalent post-prandial hyperglycemia)
Acarbose (prevalent post-prandial hyperglycemia)
Exenatide (overweight or obesity)
Sulphonylurea
DPP-4 inhibitors
Glitazone
Basal insulin (bedtime)
Exenatide (overweight or obesity)
Insulin therapy
Basal insulin + prandial insulin
With of without
Metformin
Sulphonylurea
iDPP-4 (studies currently being made)
 
(*) In order to select the second agent, we suggest looking at therapeutic drug profiles in table 7.
MONITORING AND ADJUSTMENTS IN TREATMENT AFTER 2-3 MONTHS WITH MAXIMUM EFFECTIVE DOSAGE IN ORDER TO REACH GOALS: A1C<7%, FASTING GLYCEMIA <130 mg/dL OR POST-PRANDIAL GLYCEMIA (2 HOURS) <180 mg/dL
STAGE 3: ADD A THIRD ORAL AGENT OR INTENSIFY INSULIN TREATMENT
  
Add a third oral agent with a different action mechanism. If in 2 or 3 months the targets of A1C<7%, fasting glycemia <130 mg/dL or post-prandial glycemia (2 hours) <180 mg/dL are not reached, start insulin therapy.
Intensify insulin therapy until the A1C<7%, fasting glycemia<130 mg/dL or post-prandial glycemia (2 hours) <180 mg/dL goals are reached.
INSTRUCTIONS AND ADDITIONAL COMMENTS
1.Similarly to any other Guideline, this Algorithm contains general recommendations about the most highly indicated therapeutic options for each clinical situation. The choice of the best therapeutical plan must be made based on medical judgment, in patient's options and in treatment costs with the respective drugs.
2.For further information on the potential of A1C level reduction of different drugs, please refer to table 6, in Module 4.
3.For further summarized information on therapeutic and usage safety profile of several drugs, please refer to table 7, in Module 4.
Abbreviations:
A1C = glycated hemoglobin; inhibitors ofDPP-4 (dipeptidyl peptidase-4 ); OAD = oral antidiabetic drugs.