No
Step 1. Metformin
If no contraindications start monotherapy with metformin.
- Metformin 500mg od
- Uptitrate to 500mg bd after one week if tolerated.
- Uptitrate to Meformin 850mg bd after a fortnight if tolerated.
- Monitor fasting capillary glucose (FCG) 3X weekly.
- If FCG > 6.0 mmol/L > 2 out 3 occasions for a fortnight then proceed to Step 2 .
- At all stages review concordance with all measures for glycaemic control.
- If there is intolerance to metformin at any dose then go back to the previous dose and increase metformin dose in a week.
- If increased dose not tolerated but tolerated dose > 500mg bd then keep on tolerated dose and proceed with Step 2 as outlined below.
- If completely intolerant to Metformin then initiate treatment with Pioglitazone (consider fracture risk , do not use > 10% www.shef.ac.uk/FRAX/ to caculate) or Glicazide if no cardiovascular risk instead and titrate as per Step 2. Sitagliptin could be an option here but limited data at present but is weight neutral, so if BMI > 30 consider this agent (100mg od). Rosiglitazone should be considered in the early management of disease if no evidence of ischaemic heart disease of low fracture risk.
Step 2. Second agent
If contraindicaitons to metformin but not Pioglitazone, if intolerant to metformin or if on maximum tolerated metformin and fasting capillary glucose (FCG) or HbA1c targets not met then:
- Pioglitazone 30mg od
- Increase to 45mg after 6 weeks if FCG or HbA1c targets not achieved.
If contraindications to Metformin and Pioglitazone then treat Glicazide monotherapy titrated as per Step 3 or sitagliptin, if BMI>30 and consider Acarbose or switch to insulin.
Step 3.
On maximum tolerated dual therapy with metformin and Pioglitazone but FPG > 7.0 mmol/L > 2 out 3 occastions per week?
