Diabetes Metab J.  2017 Oct;41(5):337-348. 10.4093/dmj.2017.41.5.337.

Antihyperglycemic Agent Therapy for Adult Patients with Type 2 Diabetes Mellitus 2017: A Position Statement of the Korean Diabetes Association

• Ko SH
• Hur KY
• Rhee SY
• Kim NH
• Moon MK
• Park SO
• Lee BW
• Kim HJ
• Choi KM
• Kim JH
• Committee of Clinical Practice Guideline of Korean Diabetes Association

• KMID: 2392476
• DOI: http://doi.org/10.4093/dmj.2017.41.5.337

Abstract

In 2017, the Korean Diabetes Association (KDA) published a position statement on the use of antihyperglycemic agents for patients with type 2 diabetes mellitus (T2DM). The KDA regularly updates its Clinical Practice Guidelines, but since the last update in 2015, many results from clinical trials have been introduced, and domestic data from studies performed in Korean patients with T2DM have been published. Recently, evidence from large clinical studies assessing cardiovascular outcomes following the use of sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists in patients with T2DM were incorporated into the recommendations. Additionally, new data from clinical trials using dipeptidyl peptidase 4 inhibitors and thiazolidinediones in Korean patients with T2DM were added. Following a systematic review and assessment of recent evidence, the KDA updated and modified its clinical practice recommendations regarding the use of antihyperglycemic agents and revised the treatment algorithm for Korean adult patients with T2DM.

Keyword

Diabetes mellitus, type 2; Hypoglycemic agents; Insulin; Practice guideline

MeSH Terms

Adult*
Diabetes Mellitus, Type 2*
Dipeptidyl-Peptidase IV Inhibitors
Glucagon-Like Peptide 1
Humans
Hypoglycemic Agents
Insulin
Thiazolidinediones
Dipeptidyl-Peptidase IV Inhibitors
Glucagon-Like Peptide 1
Hypoglycemic Agents
Insulin
Thiazolidinediones

Figure

• 

  Fig. 1 Antihyperglycemic therapy algorithm for adult patients with type 2 diabetes mellitus (T2DM). The algorithm stratifies the choice of medications for T2DM based on initial glycosylated hemoglobin (HbA1c) levels and demonstrates drug arrangement in a centrifugal direction. This algorithm includes only U.S. Food and Drug Administration-approved classes of medications for T2DM that are prescribed in Korea. For newly diagnosed T2DM, begin with lifestyle modification (LSM) at the time of diagnosis and subsequently maintain these changes for the duration of treatment. The HbA1c target is <6.5%; if this is not achieved within 3 months after implementing LSM, then the use of an antihyperglycemic agent should be initiated promptly. If the HbA1c level is <7.5%, metformin monotherapy is the preferred choice for pharmacotherapy in conjunction with LSM. If there are contraindications for metformin or side effects, then consider other monotherapy options such as a dipeptidyl peptidase 4 inhibitor (DPP4i), sodium-glucose cotransporter 2 inhibitor (SGLT2i) thiazolidinedione (TZD), glucagon-like peptide 1 receptor agonists (GLP-1RAs), sulfonylurea (SU), α-glucosidase inhibitor (AGI), 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. In this case, a second-line drug is added to metformin; however, any other combination of drugs with different mechanisms of action can be used depending on the patient's clinical characteristics. If the HbA1c target is not achieved within 3 months after commencing dual therapy, then proceed to triple combination therapy. In no particular order of preference, efficacy, risk of hypoglycemia, weight gain, impact on cardiovascular (CV) outcomes, and presence of clinical data in the Korean population should be considered for this arrangement. To aid the physician's choice, the characteristics of antihyperglycemic agent classes are shown as a bar scale. Efficacy (green), hypoglycemia risk (red), body weight gain (yellow), and CV benefit (blue color) were assigned ratings of low, intermediate, or high based on recently published studies identified in an extensive literature review; the scale bar is not constructed according to strict definitions but should be used as a guide for clinical decisions. GLN, glinide (meglitinide). aGLN can be used as dual combination therapy with metformin, TZD, AGI, or insulin or as a triple combination therapy with metformin and AGI, metformin and TZD, or metformin and insulin.

• 

  Fig. 2 Treatment algorithm for insulin therapy. (A) Initiation of insulin treatment. If the initial glycosylated hemoglobin (A1C) level is >9.0% and symptomatic hyperglycemia or metabolic decompensation is present, insulin therapy can be initiated with or without oral antihyperglycemic agents (OHAs) in patients with newly diagnosed type 2 diabetes mellitus (T2DM). If the HbA1c target range is not achieved after implementing a basal insulin regimen, then proceed to intensification treatment, for example, addition of a glucagon-like peptide 1 receptor agonist (GLP-1RA) or a prandial insulin or switching to a premixed insulin regimen. (B) For adult patients with T2DM who have not achieved their glycemic target following adequate treatment using OHAs. When OHAs fail, proceed to basal insulin either with or without OHAs. The addition of a GLP-1RA or switching to a premixed insulin regimen could be another option depending on the patient's clinical situation. The width of each black line reflects the strength of the expert consensus recommendations.

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