2008 Clinical Practice Guidelines - Canadian Diabetes Association

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2008 CLINICAL PRACTICE GUIDELINES S52 rine response but not hypoglycemic symptom threshold after intensive therapy in type 1 diabetes. Am J Med. 1994;97:535-542. 72. Liu D, McManus RM, Ryan EA. Improved counter-regulatory hormonal and symptomatic responses to hypoglycemia in patients with insulin-dependent diabetes mellitus after 3 months of less strict glycemic control. Clin Invest Med. 1996;19:71-82. 73. Lingenfelser T, Buettner U, Martin J, et al. Improvement of impaired counterregulatory hormone response and symptom perception by short-term avoidance of hypoglycemia in IDDM. Diabetes Care. 1995;18:321-325. 74. Kinsley BT,Weinger K, Bajaj M, et al. Blood glucose awareness training and epinephrine responses to hypoglycemia during intensive treatment in type 1 diabetes. Diabetes Care. 1999;22: 1022-1028. 75. Schachinger H, Hegar K, Hermanns N, et al. Randomized controlled clinical trial of Blood Glucose Awareness Training (BGAT III) in Switzerland and Germany. J Behav Med. 2005; 28:587-594. 76. DeVries JH, Lindholm A, Jacobsen JL, et al; Tri-Continental Insulin Aspart Study Group. A randomized trial of insulin aspart with intensified basal NPH insulin supplementation in people with type 1 diabetes. Diabet Med. 2003;20:312-318.
Pharmacologic Management of Type 2 Diabetes Canadian Diabetes Association Clinical Practice Guidelines Expert Committee The initial draft of this chapter was prepared by William Harper MD FRCPC, Amir Hanna MB BCh FRCPC,Vincent Woo MD FRCPC, Keith G. Dawson MD PhD FRCPC, Jean-François Yale MD CSPQ, Lori MacCallum BScPhm PharmD, Maureen Clement MD CCFP, Scot Simpson BSP PharmD MSc and Maryann Hopkins BSP CDE KEY MESSAGES • If glycemic targets are not achieved within 2 to 3 months of lifestyle management, antihyperglycemic pharmacotherapy should be initiated. • Timely adjustments to and/or additions of antihyperglycemic agents should be made to attain target A1C within 6 to 12 months. • In patients with marked hyperglycemia (A1C ≥9.0%), antihyperglycemic agents should be initiated concomitantly with lifestyle management, and consideration should be given to either initiating combination therapy with 2 agents or initiating insulin. INTRODUCTION As people with type 2 diabetes form a heterogeneous group, treatment regimens and therapeutic targets should be individualized. Blood glucose (BG) levels close to the normal range should be the goal for individuals in whom it is deemed safe. As type 2 diabetes is characterized by insulin resistance and ongoing decline in beta cell function, glucose levels will likely worsen over time (1) and treatment must be dynamic. The number of available antihyperglycemic agents is expanding, requiring the clinician to consider many of the following factors when choosing medications: degree of hyperglycemia, risk of hypoglycemia, medication side effects, concomitant medical conditions, ability to adhere to regimen and patient preferences. Lifestyle modification, including nutritional therapy and physical activity, should continue to be emphasized while pharmacotherapy is being used. TREATMENT REGIMENS The diagnosis of type 2 diabetes is often delayed, and 20 to 50% of people with type 2 diabetes present with microvascular and/or macrovascular complications at the time of diagnosis (2,3).When lifestyle interventions fail to control BG levels adequately, pharmacologic treatment becomes necessary. In the face of more severe hyperglycemia (i.e. glycated hemoglobin [A1C] ≥9.0%), combinations of agents are usually required.The lag period before adding other antihyperglycemic agent(s) should be kept to a minimum, taking into account the characteristics of the different medications.With timely adjustments to and/or additions of antihyperglycemic agents, the target A1C level should be attainable within 6 to 12 months. In general, A1C will decrease by about 0.5 to 1.5% with monotherapy, depending on the agent used and the baseline A1C level (4). Generally, the higher the baseline A1C, the greater the A1C reduction for each given agent. In general, as A1C levels decrease toward normal levels (
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2008 Clinical Practice Guidelines - Canadian Diabetes Association

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