Management Drug Therapy
Stepwise plan for treatment of type 2 Diabetes
Overall management plan.
Drug therapy
Diagnosis Hyperglycaemia (high blood sugar)
Non drug treatment Diet and Exercise ---------------------------------------- OK
Decision on pharmacological (drug) treatment
Patient selection.
Non Obese Obese Post-Prandial Hyperglycaemia
(high blood sugar after meals)
Insulin resistant
1st drug selection 
Sulfonylureas Biguanides Insulin sensitizers Acarbose ------- OK
(Metformin) (Alpha Glucosidase Inhibitors)
failed
Combined oral therapy Sulfonylureas + Biguanides or Insulin sensitizers ------- OK
or Alpha Glucosidase Inhibitors
failed
Failure of oral combined therapy
Insulin
Combined Insulin & Oral therapy 
Sulfonylureas Biguanides Insulin sensitizers Acarbose
(if residual insulin) (if weight excess) (if insulin resistance) (if glucose instability)
Guidelines for usage of Oral hypoglycemic agents (OHA).
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Most Type 2 patients should be given a trial with diet and exercise for an adequate period (usually 4-6 weeks) before using oral hypoglycemic agents (OHA). |
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In patients with fasting blood glucose levels more than 200 mg %, or in patients with significant symptoms, OHA therapy can be started along with diet and exercise. This will allow a more rapid relief of symptoms. |
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Oral hypoglycemic agents (OHA) are contraindicated (not indicated) in pregnancy. |
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The initial dose of oral hypoglycemic agents must be small (usually half to one tablet daily). |
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Oral hypoglycemic agent's dose increments must be made in small amounts (half to one tablet at one time ) and gradually (every 1-2 weeks), till optimal control is reached. |
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If expected response is not seen with these dosages, it would be prudent to "review" the patient clinically, check diet and exercise compliance, look for presence of conditions which may interfere with ,or antagonize, the action of oral agents, rather than keep on blindly increasing the dose of the oral agent. |
Conditions which can interfere with the action of oral hypoglycemic agents are
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Presence of any infection; specially tuberculosis and urinary tract infection etc. |
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Associated use of drugs which increases the blood sugar levels. |
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Endocrine (hormonal) causes associated with hyperglycemia, etc. |
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When a OHA does not show the desired effect, a change to another OHA of the same class is usually unlikely to improve control. Consider addition of another type of OHA or insulin. |
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It may be preferable to add insulin to those failing on OHA alone in normal weight, and especially, underweight patients. |
Once optimal control is achieved
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Re-enforce the importance of diet and exercise. |
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Efforts must be made to reduce the dose of OHA slightly, to see if the control is maintained; the rationale for this is to try and obtain the optimal target level for the individual with the smallest possible dose. |