Selection of initial antihyperglycemic agents

Choice of initial therapy is complex and depends on multiple factors including the patient's initial A1C, the agent's effect on glucose-lowering, cost, side effects, contraindications, dosing frequency, and acceptability to patients. Initial treatment for most patients is a single oral agent, although insulin may be preferred if the patient has very high initial blood glucose levels, is underweight, losing weight, or is ketotic (see Figure 3.5). Metformin, SUs, and TZDs are the most commonly used first-line agents, although the role for TZDs may change given increasing safety concerns. From a practical standpoint, glinides, AGIs, pramlintide, exenetide and gliptins are seldom used as first-line agents due low glucose-lowering potential, poor patient tolerability, and/or the need for injection.

There is an emerging consensus that, as long as there are no contraindications, metformin should be initiated, concurrent with lifestyle intervention, at the time of diabetes diagnosis. This opinion was recently published as a joint consensus guideline of the ADA and the EASD [3]. The recommendation is based on the fact that patient adherence with diet, weight reduction, and regular exercise is not sustained in most patients, and most patients will ultimately require treatment. Early institution oftreatment for diabetes, at a time when the A1C is not significantly elevated, has been associated with improved glycemic control over time and decreased long-term complications [25]. Since metformin is usually well-tolerated, does not cause hypoglycemia, has favorable effects on

Figure 3.5 Potential treatment algorithm for patients with diabetes

Therapy

Advantages

Disadvantages

Initial therapy

Recommended

Decrease body weight and increase physical activity

Metformin

(Choose if no contraindications)

Improves CVD risk factors

No hypoglycemia Weight loss/neutral Inexpensive

Difficult to achieve and maintain

GI side effects

Alternative to metformin

Insulin

(Choose if very hyperglycemic, ketotic, thin and/or losing weight)

See recommended second agents

Most effective Relatively inexpensive

Injections Monitoring Hypoglycemia Weight gain

Second agent (in addition to intial therapy)

Recommended

Sulfonylurea

GLP-1 analog OR

Gliptin OR

Thiazolidinedione

Inexpensive

No hypoglycemia Weight loss

No hypoglycemia

No hypoglycemia

Hypoglycemia Weight gain

Injections GI side effects Expensive

Limited long- term data Expensive

Weight gain CHF

Increased fracture risk Possible increased CVD risk Expensive

Alternative

Insulin

(Choose if very hyperglycemic, ketotic, thin and/or losing weight)

See above

See above

Third agent (in addition to above)

Recommended

Insulin

See above

See above

Alternative

Choose additional recommended second agent

See above

See above

body weight, and is relatively inexpensive, potential benefits of early initiation of medication appear to outweigh potential risks.

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Keep Your Weight In Check During The Holidays

A time for giving and receiving, getting closer with the ones we love and marking the end of another year and all the eating also. We eat because the food is yummy and plentiful but we don't usually count calories at this time of year. This book will help you do just this.

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