Type 2 Treatment Algorithm

1. Creatinine > =1.4 (Renally impaired) Rx insulin OR diet AND avoid biguanides or SASKA's, Begin Insulin

2. Creatinine < 1.4 (Intact renal function)

   1. BMI >=30 (Obese) BEGIN metformin therapy ± Accomplia or Xenical

      1. A1c <8% CONTINUE metformin if tolerated at <= 2g/day

      2. A1c >=8% ADD Precose

         1. A1c < 8% CONTINUE Precose if tolerated

         2. A1c >=8% ADD Byetta, then insulin

         3. A1c >=8% AND metformin NOT tolerated ADD Precose AND/OR Byetta, then insulin

   2. BMI < 30 BEGIN with Diet Therapy

      1. A1c <8% then CONTINUE diet

      2. A1c >=8% ADD Januvia

         1. A1c < 8% CONTINUE Januvia if tolerated at <= 45 mg/day

         2. A1c >=8% ADD Precose or STOP Januvia and BEGIN insulin

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The NDC considers the following Rx algorithm published by the ACP as somewhat harmful and misguided due to its recommendation of (1) KATP- channel antagonists which cause coronary vasoconstriction (sulfonylureas) as first line therapy (2) A1c action points of >7% which in the absence of any corroberating data appear overly tight and may lead to excessive hypoglycemia, morbidity, and mortality and (3) triple therapy which has no long-term safety data to recommend it:-

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