eMedinewS Editorial

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18th July, 2010, Sunday

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Managing diabetes in 2010

  • Start with lifestyle intervention first, at the time of diagnosis. If lifestyle intervention has not produced a significant reduction in symptoms of hyperglycemia or in sugar values after one or two weeks, add the first drug.
  • If no contraindications, always start with metformin in most patients with type 2 diabetes. But, consider insulin as first-line drug in those presenting with A1C >10%, fasting sugar >250 mg/dL, random sugar consistently >300 mg/dl, or ketonuria.
  • Avoid metformin if predisposing factors to lactic acidosis are present; instead consider a shorter-duration sulfonylurea. Those who cannot be given metformin or sulfonylureas, repaglinide is an alternative, particularly in patients with chronic kidney disease at risk for hypoglycemia.
  • Pioglitazone may also be considered in patients with lower initial A1C values or if there are specific contraindications to sulfonylureas. There is a concern about atherogenic lipid profiles and a potential increased risk for cardiovascular events with rosiglitazone.
  • Consider sitagliptin as monotherapy for those intolerant to or with contraindications to metformin, sulfonylureas, or thiazolidinediones. It may be the initial choice in a patient with chronic kidney disease at risk for hypoglycemia.
  • It is however, less potent than repaglinide. Start therapy with insulin if it is difficult to distinguish type 1 from type 2 diabetes.
  • Adjust therapy every three months based on the A1C result aiming it close to the non diabetic range. If A1C remains >7 %, another drug should be added within two to three months of initiation of the lifestyle intervention and metformin.

Dr KK Aggarwal
Editor in Chief