2023 Clinical Practice Guidelines for Diabetes Management in Korea: Full Version Recommendation of the Korean Diabetes Association - PubMed (original) (raw)

Fig. 2.

Pharmacotherapy of type 2 diabetes mellitus algorithm. Implement and monitor diabetes self-management education immediately upon diagnosis. Prioritize treatment, including insulin, for severe symptomatic hyperglycemia. If comorbid atherosclerotic cardiovascular disease (ASCVD), heart failure (HF), or chronic kidney disease (CKD) is present, prioritize sodium-glucose cotransporter-2 inhibitor (SGLT2i) or glucagon-like peptide-1 receptor agonist (GLP-1RA), whichever has demonstrated clinical benefit for each condition. In the absence of these conditions, metformin monotherapy is common, but other members of the class may be used based on patient condition and drug characteristics. If glycemic goals are not achieved with monotherapy, combination therapy with other classes of drugs may be considered based on drug characteristics. Patients with comorbid ASCVD, HF, or CKD who are using an SGLT2i or GLP-1RA may be added to metformin, with preference given to drugs from other classes that have demonstrated clinical benefit for each condition. Combination therapy may be initiated earlier in the course of diagnosis to reduce the risk of glycemic control failure, with early combination therapy strongly considered, especially if glycosylated hemoglobin (HbA1c) is greater than 7.5% or greater than 1.5% above target. If glycemic goals are not achieved with a combination of oral hypoglycemic agents, GLP-1RAs or basal insulin should be considered first, and a combination of GLP-1RAs or basal insulin, or insulin intensification, may be used to improve glycemic control. (1) A history of an acute coronary syndrome or myocardial infarction, stable or unstable angina, coronary heart disease with or without revascularization, other arterial revascularization, stroke, or peripheral artery disease assumed to be atherosclerotic in origin; (2) Current or prior symptoms of HF with documented HF with reduced ejection fraction (left ventricular ejection fraction [LVEF] ≤40) or HF with preserved ejection fraction (LVEF >40); (3) Estimated glomerular filtration rate <60 mL/min/1.73 m2 or urine albumin-creatinine ratio ≥30 mg/g; (4) Dulaglutide, liraglutide, semaglutide; (5) Dapagliflozin, empagliflozin; (6) Dapagliflozin, empagliflozin, ertugliflozin; (7) Pioglitazone. ASCVD, atherosclerotic cardiovascular disease; TZD, thiazolidinedione; DPP-4i, dipeptidyl peptidase-4 inhibitor; SU, sulfonylurea; α-GI, α-glucosidase inhibitors; OAD, oral antidiabetic drug.