Practical and Financial Considerations
The authors advise practitioners to “consider the significant expense and additional complexity and costs of multiple combinations of glucose-lowering medications” and caution avoidance of “overly burdensome regimens.” They note that the inability to achieve glycemic target with an “increasingly convoluted regimen should prompt a pragmatic reassessment of the HbA1c target or, in the very obese, consideration of nonpharmacologic interventions, such as bariatric surgery.”2
They emphasize the importance of nutritional counseling, diabetes self-education, and cognizance of frequently-encountered comorbidities, such as coronary artery disease, heart failure, renal and liver disease, dementia, and the likelihood of hypoglycemia. The authors highlight the importance of taking cost into account when designing a regimen. They suggest that generic drugs might be substituted when possible, and that combination products may reduce pill burden. They also note that the recommendations will likely be updated again in the coming years, as new data emerge.
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- Groop PH, Del Prato S, Taskinen MR, et al. Linagliptin treatment in subjects with type 2 diabetes with and without mild-to-moderate renal impairment. Diabetes Obes Metab. 2014;16:560–568.
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- Balena R, Hensley IE, Miller S, Barnett AH. Combination therapy with GLP-1 receptor agonists and basal insulin: a systematic review of the literature. Diabetes Obes Metab. 2013;15:485–502.
- Charbonnel B, Bertolini M, Tinahones FJ, et al. Lixisenatide plus basal insulin in patients with type 2 diabetes mellitus: a meta-analysis. J Diabetes Complications. July 2014 [Epub ahead of print].
- Davidson MB, Raskin P, Tanenberg RJ, et al. A stepwise approach to insulin therapy in patients with type 2 diabetes mellitus and basal insulin treatment failure. Endocr Pract. 2011;17:395–403.
- Rosenstock J, Jelaska A, Frappin G, et al. Improved glucose control with weight loss, lower insulin doses, and no increased hypoglycemia with empagliflozin added to titrated multiple daily injections of insulin in obese inadequately controlled type 2 diabetes. Diabetes Care. 2014;37:1815–1823.