Application of clinical judgment and guidelines to achieving glycemic goals in type 2 diabetes: focus on pharmacologic therapy.

Successful management of patients with type 2 diabetes mellitus requires attention to 4 pillars of care: diet, exercise, blood glucose monitoring, and pharmacologic therapy. For pharmacologic therapy, the availability of multiple drugs in different classes can make choices regarding initiation and intensification of treatment challenging. This article, focusing on clinical practice, reviews and provides guidance on assessing recommendations made by the latest diabetes guidelines for pharmacotherapy published by the American Diabetes Association and the American Academy of Clinical Endocrinologists. The article discusses how diabetes guidelines evolved, their move toward personalization of therapy, and their effective use in clinical practice. An appraisal of various pharmacologic strategies is integrated with the author's approach to achieving glycemic goals with a minimum of weight gain or hypoglycemic episodes. Using patients' baseline glycated hemoglobin levels and the degree to which their fasting and postprandial plasma levels contribute to their hyperglycemia is explained as a strategy by which drugs can be chosen that act on these parameters. Lifestyle interventions such as diet and exercise should continue to form the foundation of the therapeutic alliance between the clinician and patient as pharmacologic therapy is initiated or intensified.