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Abstract
For patients with newly diagnosed type 2 diabetes mellitus (T2DM), lifestyle modifications including medical nutrition therapy, weight control, physical activity, smoking cessation, and avoidance of alcohol abuse should be initiated. Metformin must be considered as the first-line oral glucose-lowering therapy, but other drugs such as dipeptidyl peptidase 4 (DPP-4) inhibitors, sodium-glucose cotransporter 2 (SGLT-2) inhibitors, thiazolidinediones, glucagon-like peptide 1 receptor agonists, sulfonylureas, glinides, α-glucosidase inhibitors, and insulin can be considered based on patient circumstances. If the initial HbA1c level of a patient is ≥ 7.5% or the HbA1c target is not achieved within three months of initiating monotherapy, dual combination therapy can be considered. If the HbA1c target is not achieved within 3 months of initiating dual therapy, a third agent with a complementary mechanism of action can be added for triple combination therapy. In addition, evidence from large clinical studies assessing cardiovascular outcomes following the use of SGLT-2 inhibitors in T2DM patients with cardiovascular risk factors have been incorporated into the updated recommendations.
Figures and Tables
Fig. 1
Adapted from the 2019 treatment guideline for diabetes. Seoul: SeoulMedcus; 2019. p57-64 [7].
Antihyperglycemic therapy algorithm for adult patients with type 2 diabetes mellitus (T2DM). For newly diagnosed T2DM patients, begin with lifestyle modifications at the time of diagnosis and maintain these for the duration of treatment. If the HbA1c target is not achieved within 3 months, then an antihyperglycemic agent should be initiated promptly. Metformin monotherapy is the preferred first choice. But if there are contraindications for metformin or side effects, then consider other monotherapy options such as a dipeptidyl peptidase 4 inhibitor (DPP-4i), sodium-glucose cotransporter 2 inhibitor (SGLT-2i), thiazolidinedione (TZD), glucagon-like peptide 1 receptor agonists (GLP-1 RAs), sulfonylurea (SU), α-glucosidase inhibitor (α-Gi), or insulin as the initial therapy according to the patient's condition. If the initial HbA1c level is ≥ 7.5% or the HbA1c target is not achieved within 3 months of monotherapy, dual combination therapy can be considered. If the HbA1c target is not achieved within 3 months after commencing dual therapy, then proceed to triple combination therapy.
CV, cardiovascular; GLN, glinide.
Efficacy (green), CV benefit (blue), hypoglycemia risk (red), and body weight changes (yellow*) were assigned ratings for low, intermediate, or high (body weight changes*; decrease, neutral, or increase); the scale bar is not constructed according to strict definitions but should be used as a guide for clinical decisions.
*Body weight changes: decrease, neutral, or increase, †GLN can be used as dual combination therapy with metformin, TZD, α-Gi, or insulin or as a triple combination therapy with metformin and α-Gi, metformin and TZD, or metformin and insulin.
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