[RobLL]

I saw this, this morning on the Diabetes in Control Web site. This is the gist of a joint recommendation from the American Diabetes Assoc, and the European equivalent. As I mentioned on my training log, most of this was conspicuously true two or more years ago. Adam Campbell and others drew my attention to Web sites which were close to these recommendations. I just added 2 and 2 together, and ended up putting myself on over the counter insulin over a year ago.

Step 1 is lifestyle intervention and use of metformin because of its effect on glycemia, absence of weight gain or hypoglycemia, good tolerability profile, and relatively low cost. Lifestyle changes should aim to improve glucose levels, blood pressure, and lipid levels, and to promote weight loss or at least to avoid weight gain. As tolerated, metformin should be titrated to its maximally effective dose at 1 to 2 months.

Step 2 is to add another medication, either insulin or a sulfonylurea, within 2 to 3 months of starting step 1 or at any time when target hemoglobin A1c level is not achieved or if metformin is contraindicated or poorly tolerated. For patients who have hemoglobin A1c level of more than 8.5% or symptoms secondary to hyperglycemia, insulin is preferred, typically a basal (intermediate- or long-acting) insulin.

Step 3 involves further adjustments by starting or intensifying insulin therapy with additional injections that might include a short- or rapid-acting insulin given before selected meals to curtail postprandial hyperglycemia. Insulin secretagogues (sulfonylurea or glinides) should be discontinued, or tapered and then discontinued, once insulin injections are started.
The tier 2 algorithm consists of less well-validated therapies that may be considered in selected clinical settings, such as in patients with hazardous jobs that would make hypoglycemia particularly dangerous. In these patients, adding exenatide or pioglitazone may be considered, although rosiglitazone is not recommended.