Antihyperglycemic therapy, type 2 DM, 2018 ADA

When A1C is ≥ 9% (75 mmol/mol), consider initiating dual combination therapy (Fig. 8.1) to more expeditiously achieve the target A1C level.

If the A1C target is notachievedafterapproximately 3months and patient does not have atherosclerotic cardiovascular disease (ASCVD), consider a combination of metformin and any one of the preferred six treatment options: sulfonylurea, thiazolidinedione, DPP-4 inhibitor, SGLT2 inhibitor, GLP-1 receptor agonist, or basal insulin (Fig. 8.1); the choice of which agent to add is based on drugspecific effects and patient factors (Table 8.1). For patients with ASCVD, add a second agent with evidence of cardiovascular risk reduction after consideration of drug-specific and patient factors (see p. S77 CARDIOVASCULAR OUTCOMES TRIALS).

---

Table 8.1 —Drug-specific and patient factors to consider when selecting antihyperglycemic treatment in adults with type 2 diabetes

---

Table 8.1 —Drug-speci fic and patient factors to consider when selecting antihyperglycemic treatment in adults with type 2 diabetes

ASCVD 
  1. Potential benefit : metformin, pioglitazone
  2. Benefit : canagliflozin, empagliflozin, liraglutide
  3. 나머지는 neutral

Heart failure
  1. Benefit : canagliflozin, empagliflozin 
  2. Potential risk : saxagliptin, alogliptin
  3. Increased risk : thiazolidinediones

---

Consider initiating combination insulin injectable therapy (Fig. 8.2) when blood glucose is ≥ 300 mg/dL (16.7 mmol/L) or A1C is ≥ 10% (86 mmol/mol) or if the patient has symptoms of hyperglycemia (i.e., polyuria or polydipsia).