1. Therapy of Type 2 Diabetes Mellitus: UPDATE
Glycemic Goals in the Care of Patients with Type 2 Diabetes ADA and AACE Guidelines:
Room For Improvement
(Be HAPPY/ Avoid Burnout, While Caring for Patients with DM)
Stan Schwartz MD, FACP, FACE
Affiliate, Main Line Health System
Clinical Associate Professor of Medicine, Emeritus,
U of Pa.
Part 8 1

2. Non-Insulin Therapy for Type II Diabetes2

3. Concurrent Therapy 3

4. The ABCs of Diabetes Care: Recommended Goals
A1C
ADA recommends < 7.0% in general, < 6.0% in selected individuals
AACE/IDF recommend ≤ 6.5%
Blood pressure
< 130/80 mm Hg
Cholesterol
LDL-C: < 100 mg/dL (< 70 mg/dL in very high-risk patients)
HDL-C: > 40 mg/dL in men and > 50 mg/dL in women
Non–HDL-C: < 130 mg/dL (< 100 mg/dL in high-risk patients)
Triglycerides: < 150 mg/dL
American Diabetes Association. Diabetes Care. 2008;31(suppl 1):S12-S54.
AACE Diabetes Mellitus Clinical Practice Guidelines Task Force. Endocr Pract. 2007;13(suppl 1):3-68.
IDF Clinical Guidelines Task Force. Diabet Med. 2006;23:
AACE = American Association of Clinical Endocrinologists
IDF = International Diabetes Federation

5. Treating the ABCs Reduces Diabetic Complications
Strategy
Complication
Reduction of Complication
Blood glucose control
Heart attack
 37%1
Blood pressure control
Cardiovascular disease
Heart failure
Stroke
Diabetes-related deaths
 51%2
 56%3
 44%3
 32%3
Lipid control
Coronary heart disease mortality
Major coronary heart disease event
Any atherosclerotic event
Cerebrovascular disease event
35%4
55%5
37%5
53%4
1 UKPDS Study Group (UKPDS 33). Lancet. 1998;352:
2 Hansson L, et al. Lancet. 1998;351:
3 UKPDS Study Group (UKPDS 38). BMJ. 1998;317:
4 Grover SA, et al. Circulation. 2000;102:
5 Pyŏrälä K, et al. Diabetes Care. 1997;20:

6. Steno-2- Synergy in Care- Treating Glucose, BP, Lipids

8. USE GLP-1 RECEPTOR AGONISTS AND SGLT-2 Inhibitors for Wt. Reduction

10. - HYPERGLYCEMIA - - SGLT2 3.Muscle- Hepatic glucose production:
Non-Insulin Therapy for Hyperglycemia in Type 2 Diabetes, Treating Defronzo’s Octet: WITHOUT HYPOGLCEMIA Match Patient Characteristics to Drug Characteristics
1.Pancreatic insulin
Secretion:
Incretin, ranolazine
5.Gut CHO
Absorption:
Incretin,
Pramlintide,
Glucosidase inh. -
7.Brain-
TZD,INCRETIN,
bromocryptine
2.Pancreatic glucagon
Secretion- Incretin
8.Kidney-
SGLT2
HYPERGLYCEMIA
Peripheral
glucose
uptake De - -
3.Muscle-
TZD, Incretin
Hepatic glucose
production:
Metformin, incretin
4.Liver
6.Fat- TZD, metformin 10

11. Revised Treatment Algorithm
The New ADA Guidelines for Type 2 Diabetes: AKA- David Nathan’s Regimen- DNR- COST BASED
Revised Treatment Algorithm
Intensive insulin
At diagnosis:
Lifestyle + metformin
STEP 1
STEP 2
Tier 1*
Tier 2†
STEP 3
Add basal insulin
Add sulfonylurea
Add GLP-1 agonist
Add pioglitazone ± SU
HbA1C >7.0%
NOT Glyburide, chlorpropamide NOT Rosiglitazone

12. New ADA Guidelines- 4/20/12 SU most prominent Added back glyburide For
EUROPEAN
SENSIBILITIES
NO MEDICAL
LOGIC
Also,
SLOW
COMBO TX
Inzucchi,
Diabetologia
4/20/12