Is this patient newly diagnosed with type 2 diabetes?
Yes NoWhich of the following applies to your patient?
A1C <1.5% above their target | |
A1C ≥1.5% above their target | |
Patient has metabolic decompensation |
Are glycemic targets now being met?
Yes NoDoes this patient have clinical cardiovascular disease?
Yes NoWhat medications is this patient currently taking?
Acarbose | Meglitinide |
DPP4-i | Metformin |
GLP1RA | SU |
Insulin - basal | SGLT2i |
Insulin - mealtime | TZD |
What is the patient's eGFR?
mL/min/1.73m2SubmitIf the glycemic target is still not reached, add an agent best suited to the individual. See the following table.
Please complete step 1
*IMPORTANT* This table has been individualized and some medications may have been removed based on patient characteristics.
Click a column title to sort results by that column.
When sorting table by column, rows with equivalent values are sorted alphabetically. Therefore, the row order of equivalent values does not imply a preference. Up and down arrows (↑↓) indicate approximate relative effectiveness. Two or three arrows do not necessarily imply double or triple the effect.
Class▲ | Effect on CV outcomes (people with diabetes and CVD) | Likelihood of hypoglycemia | Effect on weight | Relative A1C lowering when added to metformin | Cost | Renal considerations | Other therapeutic considerations |
---|---|---|---|---|---|---|---|
Alpha-glucosidase inhibitor (acarbose) | Rare | Neutral | ↓ | $$ | GI side effects; requires TID dosing | ||
DPP-4 Inhibitors | Neutral: alogliptin, saxagliptin, sitagliptin | Rare | Neutral | ↓ ↓ | $$$ | Caution with saxagliptin and heart failure; Rare joint pain | |
GLP1 receptor agonists |
Liraglutide: Superior Exenatide LAR and lixisenatide: Neutral |
Rare | ↓ ↓ | ↓ ↓ to ↓ ↓ ↓ | $$$$ |
GI side-effects Gallstone disease Contraindicated: Personal or family history of MTC or MEN2 Requires SC injection |
|
Insulin |
Neutral: glargine Non-inferior to glargine: degludec |
High | ↑ ↑ | ↓ ↓ ↓ ↓ | $-$$$$ |
No dose ceiling, flexible regimens Requires SC injection |
|
Insulin secretagogue: Meglitinide | Some | ↑ | ↓ ↓ | $$ | Reduced post-prandial glycemia; requires TID-QID dosing | ||
Metformin | Rare | ↓ | N/A | $ | Some GI side effects | ||
Insulin secretagogue: Sulfonylurea | Some | ↑ | ↓ ↓ | $ |
Gliclazide and glimepiride associated with less hypoglycemia than glyburide Poor durability |
||
SGLT2 inhibitors | Canagliflozin and empagliflozin: superior | Rare | ↓ ↓ | ↓ ↓ to ↓ ↓ ↓ | $$$ |
Genital infections, UTI, hypotension Caution with renal dysfunction and loop diuretics, elderly Contraindications: Dapagliflozin and bladder cancer, canagliflozin and prior lower extremity amputation Rare DKA (may occur without hyperglycemia) |
|
Thiazoladinediones | Neutral | Rare | ↑ ↑ | ↓ ↓ | $$ |
CHF, edema, fractures, cardiovascular controversy (rosiglitazone) Contraindications: pioglitazone and bladder cancer |
*CAUTION* alpha glucosidase inhibitor (acarbose) eliminated from treatment plan on basis of low eGFR.
*CAUTION* metformin eliminated from treatment plan on basis of low eGFR.
*CAUTION* SGLT2i eliminated from treatment plan on basis of low eGFR.
*CAUTION* sulfonylreas eliminated from treatment plan on basis of low eGFR.
*CAUTION* TZD eliminated from table. Use of TZD with insulin is contraindicated
*CAUTION* SU eliminated from table. Use of a SU and meglitinide together is contraindicated; SU generally has more glucose lowering but may have more side effects (hypoglycemia)
*CAUTION* Meglitinide eliminated from table. Use of a SU and meglitinide together is contraindicated; SU generally has more glucose lowering but may have more side effects (hypoglycemia)
*CAUTION* GLP1RA eliminated from table. Use of a DPP4-i and a GLP1RA together is contraindicated; GLP1RA generally has more glucose lowering but may have more side effects (GI)
*CAUTION* DPP4-i eliminated from table. Use of a DPP4-i and a GLP1RA together is contraindicated; GLP1RA generally has more glucose lowering but may have more side effects (GI)
*CAUTION* Insulin eliminated from table. Use of TZD with insulin is contraindicated
*CAUTION* SU and meglitinide eliminated from table. Use of a SU or meglitinide when on mealtime insulin is not helpful
Note: Alpha-glucosidase inhibitor (acarbose) eliminated from table because patient is already taking a drug from that class.
Note: DPP4-i eliminated from table because patient is already taking a drug from that class.
Note: GLP1RA eliminated from table because patient is already taking a drug from that class.
Note: Insulin eliminated from table because patient is already taking a drug from that class. You could intensify insulin therapy.
Note: Meglitinide eliminated from table because patient is already taking a drug from that class.
Note: Metformin eliminated from table because patient is already taking a drug from that class.
Note: SU eliminated from table because patient is already taking a drug from that class.
Note: SGLT2i eliminated from table because patient is already taking a drug from that class.
Note: TZD eliminated from table because patient is already taking a drug from that class.