Type 2 Treatment Algorithm

1. Creatinine > =1.4 (Renally impaired) Rx insulin OR thiazolidinediones OR diet AND avoid biguanides or SASKA's

2. Creatinine < 1.4 (Intact renal function)

   1. BMI >=30 (Obese) BEGIN GLP-1 therapy

      1. A1c <8% CONTINUE GLP-1 if tolerated 

      2. A1c >=8% AND c-peptide >2.5  ADD SGLT-2

         1. A1c < 8% CONTINUE GLP-1 if tolerated

         2. A1c >=8%  ADD basal insulin AND ADJUST to keep FBS > 100 mg/dl

   2. BMI < 30 BEGIN with Diet Therapy

      1. A1c <8% then CONTINUE diet

      2. A1c >=8% AND LDL-cholesterol >=100 AND NOT using p-450 3A3,4,5 agents ADD pioglitazone

         1. A1c < 8% CONTINUE pioglitazone if tolerated at <= 45 mg/day

         2. A1c >=8% ADD insulin

      3. A1c >=8% AND thiazolidinediones NOT tolerated SWITCH to LOW-doses of "SASKA" (selective ATP-sensitive K-channel antagonist) like glimepiride (<=2mg/day) or repaglinide (<=1.5 mg/day.) If A1C stays >8% after 3-6 months SWITCH to insulin

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The NDC considers the following Rx algorithm published by the ACP as harmful and misguided due to its recommendation of (1) KATP- channel antagonists which cause coronary vasoconstriction (sulfonylureas) as first line therapy (2) A1c action points of >7% which in the absence of any corroberating data appear overly tight and may lead to excessive hypoglycemia, morbidity, and mortality and (3) triple therapy which has neither been sanctioned by FDA nor has any long-term safety data to recommend it:-

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