The American College of Endocrinology and American Association of Clinical Endocrinologists
6 recommend various treatment options depending on HbA
1c levels at diagnosis. For treatment-naïve patients with an HbA
1c level between 6% and 7%, monotherapy with metformin, a thiazolidinedione, a dipeptidyl-peptidase 4 (DPP-4) inhibitor, or an α-glucosidase inhibitor is preferred, while prandial insulin, a glinide, or a sulfonylurea are alternative options. For those with an HbA
1c level between 7% and 8%, a combination of oral agents (eg, a sulfonylurea plus metformin, a thiazolidinedione, or an α-glucosidase inhibitor; a DPP-4 inhibitor plus metformin or a thiazolidinedione) is recommended, while prandial, basal, or premixed insulin are offered as alternatives. For patients with an HbA
1c level between 8% and 10%, basal, prandial, premixed, or NPH insulin can be combined with oral agents to achieve appropriate FPG and PPG levels, though glinides and DPP-4 inhibitors are not suitable for HbA
1c levels between 9% to 10%. Finally, for those with HbA
1c levels greater than 10%, a basal-bolus or premixed insulin regimen is required.
4 If glycemic goals are not met after 2 to 3 months of therapy, a more intensive regimen should be initiated. For example, exenatide or pramlintide may be added, though pramlintide should only be used as an adjunct to prandial insulin.
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