Management of Hyperglycemia in Type 2 Diabetes

When fasting glucose levels are controlled but HbA_1c is not at goal, it is likely due to postprandial glucose excursions, and prandial insulin is indicated. Short-acting bolus insulin may be started before the evening meal, which usually has the largest carbohydrate content. Then, if needed, add it to other meals. Another option is twice-daily premixed insulin, given before morning and evening meals. This regimen lowers HbA_1c more, but it also has a greater risk of hypoglycemia and weight gain.

Metformin may be continued with basal insulin, and may allow less weight gain than insulin alone. Continuing secretagogues initially when insulin is started minimizes initial deterioration of control. But it offers little advantage after that, and thus should then be stopped. It also needs to be discontinued if prandial insulin therapy is added. TZDs should generally be stopped when starting insulin, while the GLP-1 receptor agonists may be helpful with insulin.

Summary

The clear message of these guidelines is to individualize therapy to maximize adherence and benefit. Establish a target HbA_1c goal and start with lifestyle modification with or without metformin. If HbA_1c is not at goal after 3 months, add a second and then possibly a third oral or noninsulin injectable agent from different classes based on efficacy, side effects, weight change, and cost.

Reference

• Management of Hyperglycemia in Type 2 Diabetes: A Patient-Centered Approach. Diabetes Care 2012;35:1364-79.

To listen to an interview with Dr. Skolnik and the chair of the guidelines committee, Dr. Silvio Inzucchi, going over the details of the guidelines, click here, or search for "Diabetes Core Update" in iTunes for the special June 1, 2012, issue.

Dr. Olson is a third-year resident and chief resident in the family medicine residency program at Abington (Pa.) Memorial Hospital. Dr. Skolnik is an associate director of the family medicine residency program at Abington Memorial Hospital.