Personalized therapy algorithms for type 2 diabetes: a phenotype-based approach

Figures & data

Table 1 All approved classes of glucose lowering agents in the European Union by the time of review and update of the algorithms (April 2013) are set out, describing their hypoglycemic properties on fasting plasma glucose, post prandial glucose, side-effects, and costs

Notes: *Effect: 0 = neutral; + = mild; ++ = moderate; +++ = moderate to marked; ++++ = marked; **effect: ↓ = favorable; 0 = neutral; + = mild gain; ++ = moderate gain; +++ = moderate to marked gain; ++++ = marked gain; ^$Risk: 0 = neutral; + = mild; ++ = moderate; +++ = moderate to marked; ++++ = marked; CV outcome studies, GI side-effects: + = present, − = not present, ± not assoc, with CV risk/results of CV outcome trials expected; ***cost: + = cheap; ++ = quite cheap; +++ = expensive; ++++ = very expensive; experience: + = very small; ++ = small; +++ = high; ++++ = very high, − new drug. Summary of product characteristics of each drug in the therapeutic class with link to the European Medicines Agency. Copyright © 2013 AMD. Reproduced with permission from http://www.aemmedi.it/algoritmi_en_2013/images/tabella_i.jpg.

Abbreviations: AMD, Associazione Medici Diabetologi (Italy); AGIs, alpha-glucosidase inhibitors; SUs, sulphonylureas; TZDs, thiazolidinediones; DPP4i, dipeptidyl peptidase 4 inhibitors; GLP-1 RA, glucagon-like peptide-1 receptor agonists; CV, cardiovascular; CHD, coronary heart disease; CHF, congestive heart failure; GI, gastrointestinal; URT, upper respiratory tract; UT, urinary tract; GU, genitourinary.

Table 2 Recommended associations (by the time of review and update of the algorithms in April 2013) of incretins and SGLT-2i are shown

Note: *Prescribed generically in combination with other oral hypoglycemic agents, including insulin. **But with metformin + pioglitazone = yes. ^#There are no explicit indications for sulphonylurea alone, but for metformin + sulphonylurea = yes. ^‡Basal insulin alone. Copyright © 2013 AMD. Reproduced with permission from http://www.aemmedi.it/algoritmi_en_2013/images/diapo78_algoritmi.jpg.

Abbreviations: AMD, Associazione Medici Diabetologi (Italy); SGLT-2i, sodium-glucose cotransporter type 2 inhibitors; Y, yes; N, no; Mf, metformin; Su, sulphonylurea; Pio, pioglitazone; Rep, repaglinide; Agi, alpha-glucosidase inhibitors (acarbose); Ins, insulin; Sita, sitagliptin; Vilda, vildagliptin; Saxa, Saxagliptin; Lina, linagliptin; Dapa, dapagliflozin; Exe, exenatide; Exe LAR, exenatide long-acting release; Lira, liraglutide; Lixi, lixisenatide; int, intolerance; ci, contraindications; NS, not studied.

Figure 1 HbA_1c target has been individualized based on the age of the patient and on the presence of macro-vascular diabetes complications/co-morbidities.

Notes: *Carefully evaluate (at presentation and over the course of time) glomerular filtration rate (GFR), potential hypoglycemia risks (with particular care in the use of sulfonylureas or glinides), nutritional status, and presence of comorbidities/frailty. **The HbA_1c target values proposed are intended as safe objectives, limiting the risk of hypoglycemia.
Abbreviation: HbA_1c, glycated hemoglobin.

Figure 2 The Italian algorithm.

Notes: The Italian algorithm takes into account some individual variables/main features: initial value of HbA_1c; BMI, <30 kg/m² and ≥30 kg/m²; professions associated with hypoglycemia risk such as work at high altitude, pilots, drivers, crane machinists, platform workers, etc; presence of chronic renal failure; frailty of elderly T2D patients. Copyright © 2013 AMD. Reproduced with permission from http://www.aemmedi.it/algoritmi_en_2013/algoritmi.html.
Abbreviations: AMD, Associazione Medici Diabetologi (Italy); BMI, body mass index; CRF, chronic renal failure; HbA_1c, glycated hemoglobin.