T he recent introduction of several new classes of drugs for the management of hyperglycaemia in type 2 dia- betes offers a wider choice for individualised tailored therapy in type 2 diabetes. Additionally, there have been con- troversies regarding potential adverse effects of specific drugs which may limit their widespread use or limit the choice with- in a class of drugs. Previously published treatment guidelines for type 2 diabetes experience a time-lag before publication, often omit- ting newer drugs which have been licensed. 1-3 This has led to a tendency for algorithms to rapidly become out of date. In an attempt to update an existing algorithm some guidelines have introduced unhelpful complexity for the clinician applying them in routine practice. We present a pragmatic approach for the management of hyperglycaemia in type 2 diabetes incorporating new agents licensed as glucose lowering drugs (figure 1). As hypogly- caemia and weight gain are the two major drug side-effects for some drug classes, these factors have been taken into account in the positioning of agents in the treatment algorithm. The emphasis is on individualised choice of drug combinations based initially on achieved haemoglobin A 1C (HbA 1C ) and also on current body weight or body mass index (BMI) as well as patient preference for mode of treatment delivery either orally or by subcutaneous injection. Drug choices (Algorithm A to D) The alogorithm shown in figure 1 assumes initial trial and continued reinforcement of diet, lifestyle and weight manage- ment. Additional drugs are required if the HbA 1C target is not achieved (Algorithm A to D). Drug choice is based on risks and side-effects (table 1). A: Metformin monotherapy Consider use of Glucophage SR if intolerant of immediate- release metformin. 4 B: Add-on therapy to metformin Drug choice can be made according to body weight or BMI and patient preference for mode of delivery. Fixed-dose combina- tion tablets are available for some drug options. 5 Management of hyperglycaemia in type 2 diabetes: a clinician’s algorithm MICHAEL FEHER, ALISON COX, NEIL MUNRO EDITORIAL VOLUME 8 ISSUE 1 . JANUARY/FEBRUARY 2008 3 Diet and lifestyle including weight management A C D Glycaemic target not reached (HbA 1C > 7%) Lower BMI Higher BMI oral agent subcutaneous injection B Intensified Insulin sci +/- other agent Glycaemic target not reached (HbA 1C > 7%) Glycaemic target not reached (HbA 1C > 7%) SU/Glinide TZD (pioglitazone) DPP-4i GLP-1 sci SU/Glinide TZD (pioglitazone) DPP-4i GLP-1 sci Metformin Insulin sci AGI (acarbose) AGI (acarbose) Figure 1. Algorithm for management of hyperglycaemia - type 2 diabetes Key: SU = sulphonylurea; Glinide = meglitinide; AGI = alpha glucosidase inhibitor (acarbose); GLP-1= GLP-1 agonist; DPP-4i = dipeptidyl peptidase-4 inhibitor; SCI = subcutaneous injection; TZD = thiazolidinedione. BJDVD EDITORIAL 10/3/08 6:45 pm Page 1 COPYRIGHT MEDINEWS (DIABETES) LIMITED REPRODUCTION PROHIBITED