Recommendations.

• At the time of type 2 diabetes diagnosis, initiate metformin therapy along with lifestyle interventions, unless metformin is contraindicated. (A)

• In newly diagnosed type 2 diabetic patients with markedly symptomatic and/or elevated blood glucose levels or A1C, consider insulin therapy, with or without additional agents, from the outset. (E)

• If noninsulin monotherapy at maximal tolerated dose does not achieve or maintain the A1C target over 3–6 months, add a second oral agent, a GLP-1 receptor agonist, or insulin. (E)

Prior expert consensus statements have suggested approaches to management of hyperglycemia in individuals with type 2 diabetes (98). Highlights include intervention at the time of diagnosis with metformin in combination with lifestyle changes (MNT and exercise) and continuing timely augmentation of therapy with additional agents (including early initiation of insulin therapy) as a means of achieving and maintaining recommended levels of glycemic control (i.e., A1C <7% for most patients). As A1C targets are not achieved, treatment intensification is based on the addition of another agent from a different class. Meta-analyses (98a) suggest that overall, each new class of noninsulin agents added to initial therapy lowers A1C around 0.9–1.1%. The overall objective is to safely achieve and maintain glycemic control and to change interventions when therapeutic goals are not being met.

ADA and EASD have partnered on new guidance for individualization of use of medication classes and combinations in patients with type 2 diabetes. These guidelines, to be published in early 2012, will be less prescriptive than prior algorithms, and will discuss advantages and disadvantages of the available medication classes as well as considerations for their use. For information about currently approved classes of medications for treating hyperglycemia in type 2 diabetes, see Table 10.