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• Assist provider decision-making for the treatment of hyperglycemia in patients with type 2 diabetes.
• Serves as a recommended pathway for treating hyperglycemia.
• Encourages rapidly adding additional therapy if the patient does not achieve A1C goal
• Created by a collaborative group of physicians, pharmacists and diabetes educators working to improve
• Based on recommendations from the American Diabetes Association and the American Association of
• Approved by the Pharmacy and Therapeutics (P&T) Committee.
• Updated in June 2012 to reflect recent recommendations published by the American Diabetes Association.
What changed with the Algorithm in 2012?
• The algorithm now suggests a drug treatment based on the potential to lower A1C and to help clinicians
select treatments that are most likely to help the patient achieve the goal.
• It includes recommendations on when to use DPP-4 inhibitors and when oral 3-drug combinations
How to use this tool
• The algorithm is a five step approach to managing hyperglycemia.
• Treatment decisions should be made based on A1C in addition to patient self-monitored blood glucose results.
• Assure that the dosages of medications are maximized in each step prior to advancing to the next step.
• Steps of therapy are additive, as the medications in the algorithm have synergistic effects when used
together. Do not discontinue previous steps of therapy when advancing through the algorithm unless otherwise noted.
• Refer to “Insulin initiation guidelines for type 2 diabetes mellitus” for guidance on dosing insulin.
Note: All of the medications in the algorithm are available on the Priority Health formulary. GLP-1 and DPP-4 agents have
step therapy requirements usually satisfied by maximizing metformin for 3 months, as suggested in the algorithm. Click on
the “approved drug list” for details on what is required for these agents.
• After diagnosis is made, start with step 1 recommendations:
o Referral to diabetes self-management training
o Metformin (in combination with Sulfonylurea or GLP-1 agonist if A1C >9%
• Sulfonylurea, GLP-1 agonist, pioglitazone, or DPP-4 inhibitor o If A1C 8% to <8.5%
• Sulfonylurea, pioglitazone, or GLP-1 agonist o If A1C 8.5% to <9%
• Sulfonylurea or GLP-1 agonist o If A1C >9%
• Continue adding therapy as outlined in steps 3 - 5 if the patient does not achieve an A1C <7% after 3 months.
Limitations of the algorithm
• This algorithm recommends addition of therapy based on an A1C goal of less than 7%.
• While this recommendation is appropriate for the majority of patients, Priority Health recognizes it may not
• Recent evidence suggests an A1C goal of less than 8% may be appropriate for certain patients, including
those with the following conditions: history of CABG or PTCA; diagnosis of IVD, heart failure, MI and ESRD.
• Clinicians may set an A1C goal of 6.5% for certain patients including those with a shorter duration of
diabetes, a long life expectancy, no significant CVD, and who have a lower risk of hypoglycemia.
• Additionally, certain approved treatments including pramlintide, alpha-glucosidade inhibitors, the glinides,
colesevelam, and bromocriptine are not included in this algorithm, owing to their generally lower overall glucose-lowering effectiveness, limited clinical data, and/or relative expense.
• However, these therapies may be appropriate choices in select patients.
Erica Clark, Pharm D.
Senior Clinical Pharmacy Manager
2012 Priority Health priorityhealth.com
Type 2 diabetes glycemic treatment algorithm
FBG>250mg/dl or random >300mg/dl or A1C%>10
Lifestyle + DSME + Insulin$$-$$$$ (see initiation algorithm)
A1C% 7 to <7.5
A1C% >7.5 to <8
A1C% 8 to <8.5
A1C% 8.5 to <9
A1C% >9 to <10
1. Insulin is the most effective treatment for hyperglycemia.
2. Sulfonylureas (glimepiride or glipizide) are the least expensive but have a hypoglycemia risk.
3. Add oral agents only when A1C% is within described limits, to make goal achievable. Don’t add noninsulin treatment if A1C% is not in the listed range.
4. 4-drug combinations are not supported by evidence; patients should advance to insulin treatment.
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