• Lifestyle therapy, including medically supervised weight loss, is key
• The A1C target must be individualized
• Glycemic control targets include fasting and postprandial glucose
• Choice of therapies must be individualized, based on patient characteristics that include cost to patient, formulary restrictions, and personal preferences
• Minimizing hypoglycemic risk is a priority
• Minimizing risk of weight gain is a priority
• Initial acquisition cost of medications is only part of the total cost of care, which also includes monitoring requirements, risk of hypoglycemia, weight gain, and safety
• The algorithm stratifies choice of therapies based on initial A1C
• Combination therapy is usually required and should involve agents with complementary actions
• Comprehensive management includes lipid and blood pressure therapies, when applicable, and treatment of related comorbidities
• Therapy must be evaluated frequently until stable (eg, every 3 months), and then less often
• The therapeutic regimen should be as simple as possible to optimize adherence
• The algorithm includes every FDA-approved class of medication for diabetes

Garber AJ, et al. Endocr Pract. 2016;22(1):84-113.

Medical therapy for obese patients includes only phentermine, orlistat, lorcaserin, and phentermine/topiramate ER

Liraglutide and naltrexone/bupropion added as medical therapies

SGLT-2 inhibitors should be used with caution, ranked as fifth option for monotherapy

SGLT-2 inhibitors no longer regarded as “to be used with caution” and ranked as third option for monotherapy

Add GLP-1 RA, or SGLT-2 inhibitor or DPP4-inhibitor to intensify prandial control

GLP-1 RA =glucagon-like peptide-1 (GLP-1) receptor agonists; SGLT2=sodium glucose cotransporter 2 inhibitors; DPP-4i=dipeptidyl peptidase 4 inhibitors

Garber AJ, et al. Endocr Pract. 2016;22(1):84-113.

• Maintain optimal weight
• Calorie restriction
• Plant-based diet; high polyunsaturated and monounsaturated fatty acids
• Avoid trans fatty acids; limit saturated fatty acids

• Structured counseling
• Meal replacement

• Structured counseling
• Meal replacement

• 150 min/week moderate exertion (eg, walking, stair climbing)
• Strength training
• Increase as tolerated

• Structured program

• Structured program
• Medical evaluation/clearance
• Medical supervision

• About 7 hours/night

• Screen for obstructive sleep apnea

• Screen for obstructive sleep apnea

• Community engagement
• Screen for mood disorders

• Refer to mental health professional
• Behavioral therapy

• Refer to mental health professional
• Behavioral therapy

• No tobacco products

• Structured programs

• Structured programs

• Diethylpropion
• Phendimetrazine
• Phentermine

• Orlistat
• Phentermine/topiramate extended release (ER)
• Lorcaserin
• Naltrexone/bupropion
• Liraglutide 3mg

• Metformin
• GLP1-RA
• SGLT-2i
• DPP-4i
• TZD*
• AGi
• SU/GLN*

Proceed to dual therapy if not at goal in 3 months

• GLP-1RA
• SGLT-2i
• DPP-4i
• TZD*
• Basal insulin*
• Colesevelam
• Bromocriptine QR
• AGi
• SU/GLN*

Proceed to triple therapy if not at goal in 3 months

• GLP-1 RA
• SGLT-2i
• TZD*
• Basal insulin*
• CPP-4i
• Colesevelam
• Bromocriptine QR
• AGi
• SU/GLN*

Proceed to or intensify insulin therapy if not at goal in 3 months

• Dual therapy or
• Triple therapy

Symptomatic:

• Insulin ±
• Other agents

Add to/intensify insulin