No
If no contraindications start therapy metformin.
- Metformin 500mg bd
Monitor fasting capillary glucose (FCG) 3X weekly.
Uptitrate fortnightly if FCG > 6.0 mmol/L > 2 out of 3 occasions. Stop up titration if target achieved. At all stages review concordance with all measures for glycaemic control.
Metformin intolerance?
- If there is intolerance to metformin at any dose then go back to the previous dose and increase metformin dose in a week.
- If tolerated then proceed with up titration.
- If increased dose not tolerated but tolerated dose > 500mg bd then keep on tolerated dose and add either sitagliptin 100mg or Pioglitazone 30mg and titrate this, as per the linked schedule.
- If completely intolerant to metformin then initiate treatment with sitagliptin or Pioglitazone instead and titrate as per the linked schedule.
If contraindications/intolerance to Metformin/Sitagliptin but not Pioglitazone:
- Pioglitazone 30mg od
- Glicazide 40mg bd
Uptitrate gliclazide weekly if FCG > 10.0 mmol/L > 2 out of 3 occasions.
Uptitrate fortnightly if FCG in range 6.0-9.9 mmol/L > 2 out of 3 occasions. Stop up titration if target achieved. At all stages review concordance with all measures for glycaemic control.
Dosing schedule:
- Pioglitazone remains at 30mg od
- Glicazide 80mg am, 80mg pm
- Glicazide 160mg am, 80mg pm
- Glicazide 160mg am, 160mg pm
If contraindications to Pioglitazone but not metformin then follow the pathway for those with hyperglycaemic symptoms.
If contraindications to metformin and Pioglitazone then treat with glicazide monotherapy and consider Acarbose or switch to insulin.
On maximum tolerated dual therapy with metformin and Pioglitazone but FPG > 7.0 mmol/L > 2 out of 3 occasions per week.
