Table 2.

Stepped care strategy

• Insulin is typically added relatively late in the natural history.

• Use of home glucose monitoring to guide management varies and often is not initiated until patients are treated with insulin—relatively late in the natural history.

1. All patients with prediabetes and early diabetes should have management of cardiovascular risk factors, use of aspirin (if appropriate), screening for eye and renal complications, and education in medical nutrition management.

2. If lifestyle change is insufficient to achieve glycemic goals, initiate pharmacologic therapy; usually begin with use of metformin as recommended by ADA guidelines.

3. If metformin is insufficient, add another pharmacologic agent.

• Sulfonylureas—inexpensive and cost-effective, but carry a risk of hypoglycemia

• Alternatives with less risk of hypoglycemia (GLP-1 analogs, DPP-4 inhibitors, thiazolidinediones, SGLT-2 inhibitors, α-glucosidase inhibitors, colesevelam, bromocriptine, and glinides)

4. If glycemic goals cannot be attained with two or three such agents, add insulin—either as basal insulin alone, basal plus mealtime insulin, or a premixed insulin preparation.