How to obtain appropriate type 2 diabetes control in the first 180 days of treatment initiation

Good control of diabetes provides meaningful microvascular risk reduction; yet, patients with type 2 diabetes mellitus commonly languish at unsatisfactory levels of glycated hemoglobin (HbA1c) for protracted periods. A variety of factors contribute to this clinical inertia, as clinicians tend to be too conservative in their treatment of patients who are not achieving glycemic control. Available clinical data suggest the near-maximal blood glucose reduction achievable with use of most antidiabetic agents typically occurs within several weeks of treatment initiation. Based on this time course of action, we propose that optimal glycemic control can be attained within 180 days of treatment initiation by advancing antihyperglycemic therapy more rapidly than typical current practice. Our approach builds on current recommendations, though it seeks to redefine standard management of type 2 diabetes by placing greater emphasis on the timing of treatment intensification. We recommend the total period patients spend with uncontrolled hyperglycemia be minimized by shortening the number of steps along the treatment intensification ladder. This can be achieved by establishing combination therapy early in cases where baseline HbA1c levels are markedly elevated, including the prompt addition of basal insulin therapy when it becomes apparent that oral agents alone are unlikely to attain glycemic goals.