Updated Guidelines for Treating Type 2

This week, the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) updated their recommendations for how Type 2 diabetes should be treated. The new guidelines have been published online in the journals Diabetes Care and Diabetologia and will be published in print in the January 2009 issue of Diabetes Care.


Treatment recommendations were originally published in 2006 to guide health-care providers on how to bring down high blood glucose levels in people with Type 2 diabetes. According to a statement released this week by the ADA and EASD, the latest revisions “tak[e] into account new medications that have come on the market and the most current scientific data regarding previously recommended drugs.”

The revised treatment protocol looks like this:

  • Step 1—Lifestyle changes (such as diet and exercise) and treatment with the drug metformin
  • Step 2—If blood glucose goals are not met within three months with Step 1 alone, one of the following options should be added:

    Option A is considered “well validated,” since insulin and sulfonylureas have a long track record of safely treating Type 2 diabetes, while the treatments in Option B have not been around as long. However, David Nathan, M.D., chair of the panel of experts that issued the updated treatment guidelines, stated that the Option B drugs are valuable if hypoglycemia is a major concern (since insulin and sulfonylureas have a greater risk of causing hypoglycemia than pioglitazone and exenatide).

  • Step 3: If blood glucose goals are not met with Step 1 and Step 2, then basal insulin should be added if it has not already been started, followed by more intensive insulin treatment as necessary.

The new guidelines recommend that people newly diagnosed with Type 2 diabetes see their doctors every three months, as did the old guidelines. The goal is to allow timely assessments and treatment adjustments so that people can rapidly achieve and maintain near-normal blood glucose and HbA1c levels.

The major differences in this revision of treatment guidelines are the following:

  • The removal of rosiglitazone (Avandia), the other drug in the thiazolidinedione class, from the list of recommended second-step drug options; and
  • The addition of GLP-1 agonists to the list of second-step drug options.

Rosiglitazone has been in the news frequently over the last year because of associations with heart attack, congestive heart failure, and bone fractures. The latter two side effects have also been associated with pioglitazone, though pioglitazone does not appear to increase risk of heart attack.

You can download a PDF of the Diabetes Care article outlining the revised guidelines and the research behind them here.

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  • Steve Parker, M.D.

    Thanks for linking to the PDF.

    Guidelines like this are helpful to practicing physicians, especially since there are so many options available now.

    Don’t be shy about sharing these with your doctor.

    At the start of my career, we just had insulin and sulfonylureas and diet modification.

    I’m a little surprise to see such a prominent role for Byetta since it has been around only a few years in the U.S.

    -SteveBrief biography of Steve Parker, M.D.

  • CalgaryDiabetic

    Dear Tara. When I developed diabetics 11 years ago, the GP said insulin was not allowed for type 2 before your pancreas was totally dead according to the Canadian Medical Association. This was no doubt parotted from the ADA. Mind you long acting basal insulin was not available. Now this has changed and you wonder if adding some basal insulin will prolong the life span of the damaged pancreas. The only downside I see is the weight gain that results from insulin use.

    Also what happens to people in step 1 if they do not tolerate metformin.

  • Emma

    Exactly why does insulin cause weight gain? The more insulin, the more weight gain?

  • idocmadden

    What happened to Glucophage (metformin). Most of the patients I see for eye exams are on Metformin as a first line therapy.

  • Gerri Ried

    How do I convince my doctor to take me off Actos and try Metaforim. She says Actos is doing what she wants, but I’m concerned about heart problems at my age (79).
    Please advise.

    Thank You

  • josie

    Please Note: Ihave been a diabetic for over forty
    years.Always watched my diet and what I ate,it has helpedto keep me healthy.

    thank you,


  • Airborne mom

    Metformin worked well in the beginning. Then I started having more episodes of lows. My doctor started me on Byetta. My blood sugars stay very consistent all day and night.

  • SMA1957

    I was taking Avandia and, even though I had no symptoms, I had a heart attack, that required a quadruple by-psss. Maybe the Avandia wasn’t the cause, but I refused to go back on the drug. I had discussed the drug and voiced my concern when I began the drug. My doctor assured me it was safe. No more, thank you! I feel the drug companies are pushing the doctors and the doctors push their patients.

  • Sharon

    Dear Tara,

    These are not all comments; There are questions here.

    Will anyone at DSM be responding to them, individually
    on this blog, or is it an exercise in futility to ask a


  • CalgaryDiabetic

    Dear Emma. Yes you have it right the more insulin you use the more hungry you will feel. Even worst is the more weight you gain the less well the insulin works. All of this is a positive feedback loop also know as a vicious circle. So you must try to minimise the amount of insulin used and still try to maintain the blood sugar as close to normal as possible. Sound impossible? Eating foods with a low glycimic index and limiting the carbohydrate helps and of course exercising,if you can, instead of injecting more insulin helps. In the USA there may be things like “Symlin” to curb the uncontrollable hunger not sure because it may not be available in Canada. Anyone have any other ideas?

  • Tara Dairman, Web Editor

    Hi Sharon,

    Yes, I plan to respond to all of the questions asked here as best I can–please check back later or tomorrow and I will have some responses up!

  • Tara Dairman, Web Editor

    Hi everyone—thanks for your patience. Here are my responses to the questions that have been asked so far in this comments thread.

    Idomcmadden – In the new guidelines, as with the previous guidelines, metformin is considered a first-line therapy. You will see it listed under Step 1 above, along with lifestyle changes.

    Gerri Ried – You may want to print out this blog entry, or go to the link to the guidelines in Diabetes Care, to show to your doctor to help explain why you would like to try metformin. There may be some other reasons why she is reluctant to prescribe metformin for you—for instance, it is not supposed to be taken by people who have kidney disease, liver disease, congestive heart failure, or drink alcohol regularly. Nevertheless, you should have an open discussion with her about your treatment wishes. Jan Chait’s blog entry “Put Yourself in the Driver’s Seat When it Comes to Your Health” also has a lot of great tips on how to talk to your doctor.

    Emma – Here is an excerpt from our article “Insulin Therapy for Type 2 Diabetes” about insulin and weight gain:

    Does insulin make you gain weight?

    In addition to allowing glucose in the blood to enter the cells of the body, insulin also helps the body store fat. If you don’t have enough insulin, you lose weight, and if you have too much insulin, you gain weight.

    If you routinely take more insulin (or sulfonlyureas) than your body needs, you will gain weight. This could happen, say, if you kept your blood glucose in the 60-70 mg/dl range and endured frequent bouts of hypoglycemia. If your blood glucose levels fall too low

  • Bob

    What is the problem with regular alcohol use and metformin? I know that alcohol is bad for type-2 diabetics, but what specifically is the problem with the mixture / drug? I have been a drinker (I’ll drink maybe 6 beers every 3rd day or so) and Metformin user for about 8 years. What is going to happen to me?

  • nOTE

    Thank you very much
    I’ve just heard about newly guideline today
    I’ll read it now ūüôā

  • evon

    i have a grandmother with type 2 diabetes mellitus. previously she was on metformin and glibenclamide (daonil) for few years and as with other diabetics, she had episodes of hypoglycemia and couple of times, it was so bad that she had to be rushed to the hospital.

    not long thereafter, she was then switched to gliclazide (diamicron mr). her glycemic level is now pretty much controlled as compared to before and there are lesser episodes of hypoglycemia.

    we discussed with her doctor and he mentioned something about the Advance study? may i know what is that and what it has to do with my grandmother’s health condition?

    by the way, the guidelines is pretty helpful and provides an insight to people like me to understand the disease better. thanks!

  • patricia fugett

    Do you know of any tablet (pill) that does not
    have sulfer in it for a # 2 diabetic. I am on
    Lantis shots because I am allergic to sulfer an
    cannot take the pills, and the shots causes me
    to gain lots of weight?

    Thank you for an answer: Patricia Fugett

  • Sally Mettler

    I too have started to gain weight taking insulin.I also take Junuvia. Previously when I ate a vegetarian diet I got off insulin. I’ve been taking Metformen and my doctor determined that I was allergic to it. That is why we tried Junuvia and insulin. I’m going to the doctor tommorow and I want to dtermine if he can prescribe a drug instead of insulin. Does anyone have a suggestion? I struggled to lose 47 lbs. over a 2 yr. period. In the last 6 weeks I have gained 12 lbs. I exercise 3 times a week at Curves. I enjoy it and will continue. I hate to go back to the vegetarian diet because my husband prefers regular meat eating habits.

  • Renè

    This is very interesting subjects and I get a few answers by reading these letters. My husband is on Metformen and insulin injections and gains a lot of weight because of it. I’ll suggest to him to look after his food intake and see what happens. Thank you

  • John Wesley Ilopitu

    It is not theoretical for Metformen to increase body weight, however, Insulin did. But please check the daily food intake and food content.
    Thanks Wesley Ilopitu