Joslin Diabetes Center & Joslin Clinic Clinical Guideline for ...

ANTIHYPERGLYCEMIC THERAPY continuedFasting Plasma Glucose > 140 OR2 Postprandial Plasma Glucose > 180 ORA1C ‡ 7.0%Add Third Oral Medication OR Add InsulinAdd Third OralAntihyperglycemic Agentof Different Class(No proven benefit of adding two differentinsulin secretagogues in combination)Add Insulin (*) (**)• Several options available:•Intermediate acting insulin q hs (e.g. NPH or lente)•Long-acting or basal insulin (e.g. glargine once daily at any timeor ultralente pre-supper or hs)•Pre-supper insulin mixture (e.g. 75/25 lispro, 70/30 insulin,or 70/30 aspart)• Suggested starting dose: 0.1-0.2u/kg ideal body weight• Titrate/adjust insulin dosage until glucose goals metIf target glucose not met, consider:• Changing to multidose therapy using combination of rapid or very rapidacting,intermediate, or long -acting insulin• Pre-meal rapid or very rapid-acting insulin (e.g. aspart, lispro, or regular)added to hs intermediate or long-acting/basal insulin• Adding oral medication to reduce insulin resistance or improve glycemiccontrol if already on insulin(Metformin, TZDs, sulfonylureas, and a-glucosidase inhibitors are approvedfor use in combination with insulin)• Refer to endocrinologist if goals not met* May need to taper and discontinue some or all oral agents as insulin is initiated and adjusted, particularly if using rapid-actingand basal insulins.**Pre- and postprandial blood glucose should be checked. Frequency may vary 1-4 times/day depending on individual patientand status of glycemic control.Oral Agents Available in the USABiguanides• metformin(Glucophage)• metforminextended release(Glucophage XR)(metformin andmetformin ERavailable asgenericmedication)TZDs(Thiazolidinediones)• pioglitazone(Actos)• rosiglitazone(Avandia)a-GlucosidaseInhibitors• acarb ose(Precose)• miglitol(Glyset)Insulin SecretagoguesSulfonylureas Non-sulfonylurea2 nd generation SecretagoguesD-phenylalanineDerivatives• nateglinide(Starlix)• glimepiride (Amaryl)• glipizide (Glucotrol)• glipizide extendedrelease (Glucotrol XL)• glyburide(Micronase, Diabeta)• micronized glyburide(Glynase)(glipizide and glyburide areavailable as genericmedications)Meglitinides• repaglinide(Prandin)FixedCombinations• metformin andglipizide(Metaglip)• metformin andglyburide(Glucovance)• metformin androsiglitazone(Avandamet)Copyright © 2004 by Joslin Diabetes Center. All rights reserved. These Guidelines are the property of Joslin Diabetes Center and are protected by copyright. Any reproduction of thisdocument, which omits Joslin’s name or copyright notice is prohibited. This document may be reproduced for personal use only. It may not be distributed or sold. It may not bepublished in any other format (e.g., book, article, Web site) without the prior, written permission of Joslin Diabetes Center, 617-732-2695.