Figures and Tables
Simplified flowchart for American Association of Clinical Endocrinologists (AACE)/American College of Endocrinology
(ACE) 2009 glycemic control algorithm. Pathways are provided for patients with hemoglobin Ale (A1C) in 3 ranges: 6.5% to 7.5%, >7.6% to 9.0%, and >9.0%. There is a progression from rnonotherapy, to dual therapy, to triple therapy, to insulin therapy with or without additional agents. The order of presentation of regimens indicates general priorities that should be customized to the individual patient, with consideration of contraindications and precautions, allergies, comorbid conditions, drug-drug interactions, and drug-laboratory interactions. Physicians must be thoroughly familiar with complete prescribing information before selection of therapy. In each case, response to therapy should be monitored closely (determination of A1C every 2 to 3 months), and titration of dosages or changes of regimen should be implemented in a timely manner. Rx = treatment. Note accompanying Table of Annotated Abbreviations for Figure 1.
Table of Annotated Abbreviations for Figure 1(a)
Generic name
Trade name
Glipizide (generic), Glucotrol, Glucotrol Abbreviation
a The following single-tablet combinations of agents are available: sitagliptin + metformin (Janumet), pioglitazone + metformin (ActoPlus Met), rosiglitazone + metformin (Avandamet), repaglinide + metformin (PrandiMet), glipizide + metformin (Metaglip and generic), and glyburide + metfonnin (Glucovance and generic).
Table Al. Outline of Various Types of Insulin
Type of insulin
Trade name
Rapid-acting insulin analogues
with reduced risk of hypoglycemia 2-5 hours after a meal or overnight Premixed insulin/protamine
breakfast and dinner; provides postprandial coverage with 2 injections per day; less flexible than use of basal-bolus therapy with a combination of rapid-acting and long-acting analogues Long-acting insulin analogues
patients with type 2 diabetes; excellent reproducibility of absorption profile within individuals; possibly less weight gain than with other insulins Not recommended
persistence of effect is too long to mimic a normal prandial physiologic profile; the result is impaired efficacy and increased risk of delayed hypoglycemia "peakless" basal insulin; highly variable absorption even within individuals; increased risk of hypoglycemia compared with the long-acting insulin analogues glargine or detemir TableA2 Summary of Insulin Regimens
Insulin regimen
Components and frequency of administration
Injections per day
Glargine or detemir (daily or twice a day) NovoLog Mix or Humalog Mix (usually twice a day; occasionally used daily or 3 times a day) NovoLog, Humalog, or Apidra (usually 3 times a day) NovoLog, Humalog, or Apidra (usually 3 times a day) in 4 combination with glargine or detemir (daily) Duration
Start 500 mg po bid with meals Half-life: 6.2 h 500 mg #60: 70850 mg #60 $1141000 mg #60: $142 Dipeptidyl-
Inhibitors (DDP-4)

25 mg #90 $64650 mg #30 $221100 mg #30 $216 Glucose-Like
Peptide-1 (GLP-1)

Start 5 mcg sc <1h before meals Half-life: 2.4 h Start 0.6 mg sc qd x1wk then 1.2 Half-life: 13 h Long-acting

0.1-0.2 u/kg sc hs; then adjust as Onset 5-7h; no peak; 100 u/ml (1 vial, 10 Short-acting analog

Onset < 0.25 h, Peak 100 u/ml (1 vial, 10 30% total according to 12 hour after-meal glucose reading Abbreviations: / means a ratio such as numerator divided by denominator, u/ml means units per mililiter; # means number as in dispensing;< means less than; bid means twice a day; CHO means carbohydrateER means extended release; h means hour; hs means hour of sleep, or bedtime; kg means kilograms; Max means maximummin means minute; ml means mililiter; po means orallyqd menas dailyqwk means once a weeksc means subcutaneous;tabs means tablets u means units; XR means extended release.


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