Table 1.

Simplified Overview of Algorithm

Step	Procedure
1.	Read data: patient identifier, target A1C, current medications, medication history, comorbidities, laboratory data, allergies, gender, contraindications, SMBG data.
2.	Assess whether sufficient SMBG data are available and whether glycemic patterns are sufficiently stable with respect to longitudinal date in order to be able to make recommendations.
3.	Assess current quality of glycemic control using multiple criteria (mean levels; preprandial and postprandial levels; postprandial excursions; variability; frequency, severity, and timing of hypoglycemia and hyperglycemia; and adequacy of SMBG monitoring).
4.	Identify any new contraindications (e.g., allergy; cardiac, renal, hepatic disease; pregnancy; hospitalizations); if appropriate, discontinue one or more of the current medications.
5.	Identify possible medication-related adverse events. If unacceptable and not expected to subside with temporary dosage adjustment, recommend discontinuation of that medication and replacement by another medication.
6.	Assess adequacy of current therapy for all times of day: mean, standard deviation, percentage hyperglycemic, percentage hypoglycemic.
7.	If patient has achieved goals, continue current regimen and dosages.
8.	Assess problems related to hypoglycemia at each of eight specified time periods:a identify the medications that are primarily responsible for control of blood glucose during the time periods when hypoglycemia is occurring. Recommend dosage reduction for these medications.
9.	Assess problems related to hyperglycemia at each of several (e.g., eight) specified time periods: identify the medications that are predominantly responsible for control of blood glucose during these time periods and recommend an increase in dosage of those medications if there are no problems with hypoglycemia during the time periods controlled by this same medication, provided that the dosage does not exceed the usual maximal effective dose.
10.	Assess problems related to postprandial excursions at each of the three principal meals. Identify the medications primarily responsible for control of the postprandial excursions. Make recommendations regarding the meal content (protein, fat, carbohydrate), amount or glycemic index of carbohydrates, and timing of medications with respect to meals (e.g., GLP-1 agonists, DPP-4 inhibitors, glinides, alpha-glucosidase inhibitors).
11.	Recommend advancement to the next regimen in the treatment pathway (algorithm). If the current medications have been titrated to their maximally effective doses and hyperglycemia or excessive postprandial excursions persist, then consider changing to the “next” regimen in the sequence, i.e., adding an additional agent with a different mechanism of action than the current medications.
12.	Assess adequacy of SMBG monitoring. Recommend revised schedule for SMBG testing and provide explanation/rationale.
13.	Assess complexity and cost of the current regimen; if excessively complex or costly, consider simplifying the regimen.
14.	Periodically reassess treatment goals for A1C, mean glucose, and the preprandial glucose and PPG values. If the patient is unable to achieve goal or develops new comorbidities or other factors limiting treatment, adjust goals for glycemia to keep the risk of hypoglycemia within an acceptable level.
15.	Provide explanations for recommendations, making it possible for the clinician to understand the logic being utilized by the program.
16.	Allow the clinician to accept or reject (override) recommendations.
17.	If the clinician rejects the initial set of recommendations, provide an alternative set of recommendations regarding therapy, together with explanations and rationale.
18.	Provide access to educational materials for clinician and patient.
19.	Generate instructions to be given to the patient.

^aTime periods are also designated as “time buckets,” “time windows,” or “time segments,” e.g., “before lunch,” 11:00–12:30.