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The algorithm described here was published after the continuing education article in the November 2009 issue was printed (Arnold KC. Treating type 2 diabetes. A specialist's approach. ADVANCE for Nurse Practitioners. 2009;18[11]). Nurse practitioners should consider this information in addition to the material presented in the article.
The American Association of Clinical Endocrinologists (AACE) and the American College of Endocrinology (ACE) published an updated algorithm for glycemic control in the September/October 2009 issue of Endocrine Practice. The guidelines are presented in a flowchart format designed to help simplify the treatment of patients with type 2 diabetes mellitus.
The new glycemic control algorithm is stratified on A1c ranges: 6.5% to 7.5%, 7.6% to 9.0%, and greater than 9.0%. Medication choices are listed in priority of safety, hypoglycemia risk, efficacy, simplicity and cost. Lifestyle modification and metformin continue to be the foundation of therapy. Monotherapy, dual therapy and triple therapy oral agents options are recommended.
Insulin remains the mainstay of therapy after oral agents, but it is first line in patients whose A1c is greater than 9.0%. The previous guidelines recommended insulin initiation with A1c greater than 10%.
The updated algorithm makes a strong recommendation against using regular insulin or NPH due to variability. The treatment regimen should be reassessed and modified every 2 to 3 months if the patient is not at the A1c goal of less than 6.5%.
To read the algorithm in its entirety, see http://www.aace.com/pub/pdf/GlycemicControlAlgorithmPPT.pdf.
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