TREATMENT/MANAGEMENT
Current guidelines from the American Diabetes Association/European Association for the Study of Diabetes (ADA/EASD) and the American Association of Clinical Endocrinologists (AACE) advise that in addition to a therapeutic lifestyle (adequate physical activity, healthy diet, and weight control), metformin is the drug of choice and is recommended as firstline therapy.1,2
The many available pharmacologic options can make the choice of agents after metformin use an overwhelming task, especially if the HCP has limited experience with them. The 2015 ADA/EASD and AACE algorithms help guide decision making by prioritizing the medications according to efficacy, safety, and adverse-effect profiles.1,2
Emphasis is placed on choosing medications that have low potential for hypoglycemia and, if possible, avoiding medications that may cause weight gain. Additionally, HCPs must take into account patient concerns about adverse effects, convenience/ease of use, mode of administration, and cost. Engaging patients about what is important to them and addressing their beliefs, desires, and fears are key components of individualizing therapy and are essential for successful treatment outcomes.
While Sonja’s current labs suggest that she would be an appropriate candidate for metformin, the drug’s known potential for gastrointestinal (GI) adverse effects is concerning because of Sonja’s underlying history of diarrhea-dominant irritable bowel syndrome (IBS). She remarks that while her IBS is currently controlled, she is wary of developing problems. You respond that extended-release metformin is generally better tolerated than the immediate-release preparations, but it may cost more. She considers this and is willing to try the extended-release option; you instruct her to increase her dose by one 500-mg tablet every week, as tolerated, to reduce the risk for intolerance.
You also discuss blood-glucose testing with her. While she is not taking a medication that will cause hypoglycemia, you explain that structured self-monitoring of blood glucose (SMBG) will provide her immediate feedback about the effects of her lifestyle changes, as well as the effect of the medication, on her blood sugar control.3 Her A1C of 7.2% suggests postprandial glucose (PPG) as a significant contributing factor; thus, it would be beneficial to measure this value regularly (see Figure 14).
You show Sonja the AACE and ADA therapeutic blood glucose parameters required for optimal glucose control so she can see the impact of her efforts (see Table 11,2). She is willing to test her blood sugar twice daily and agrees to test before and then two hours after a different meal each day (this is known as paired testing).5
Sonja returns two weeks later with her blood glucose log for review (see Figure 2). She is pleased with her improved glucose values but has been unable to exceed 1,000 mg/d due to frequent daytime diarrhea that interferes with work. She requests a change of medication.
Continue for therapeutic considerations >>