Practical Outline in the Management

In this chapter, a suggestion will be developed on how incretin mimetics and DPP-4 inhibitors will fit into established treatment algorithms for glycemic control in patients with type 2 diabetes (see Fig. 6A).

Fig. 6. Treatment algorithm for patients with type 2 diabetes. (a) is a simplified version of "a consensus algorithm for the initiation and adjustment of therapy" for the "management of hyperglycemia in type 2 diabetes" recently published by Nathan et al. [166,167]). ?*indicates that a higher than target range HbA1c (e.g., >7.0%) indicates the need for intensification of anti-hyperglycemic therapy. The algorithm is based on the availability of metformin, sulfonylureas, glitazones, and insulin. a-glucosidase inhibitors are not considered. (B) is a development of algorithm (A), but considering the availability of DPP-4 inhibitors (e.g., sitagliptin and vildagliptin) and incretin mimetics (e.g., exenatide). The therapeutic options at each step of intensification considerably increase in number. Dotted lines indicate that progressing through the algorithm this way may require more action than just adding the next antidiabetic drug. In some cases, contraindications need to be addressed (e.g., glitazones in combination with insulin, not approved in Europe).

Fig. 6. (continued). In other cases, especially if a more potent drug is to be added, which relies on a similar mechanism (e.g., incretin-mediated insulinotropic activity), one of the previously used antidiabetic agents may need to be discontinued (e.g., when adding a sulfonylurea or an incretin mimetic to a patient previously treated with a DPP-4 inhibitor). Note that sufficient study results (see Fig. 5) are not available for all mentioned combinations to provide a sound scientific basis for their use outside clinical studies.

Fig. 6. (continued). In other cases, especially if a more potent drug is to be added, which relies on a similar mechanism (e.g., incretin-mediated insulinotropic activity), one of the previously used antidiabetic agents may need to be discontinued (e.g., when adding a sulfonylurea or an incretin mimetic to a patient previously treated with a DPP-4 inhibitor). Note that sufficient study results (see Fig. 5) are not available for all mentioned combinations to provide a sound scientific basis for their use outside clinical studies.

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