The World Health Organization (WHO) has developed guidelines for selecting therapy for treatment intensification in type 2 diabetes and on the use of insulin (human or analog) in type 1 and 2 diabetes. These recommendations were published in the Annals of Internal Medicine.

The target population comprises adults with type 1 or 2 diabetes who reside in low-resource settings in low- or high-income countries; the guidelines are also applicable to disadvantaged populations living in high-income countries.

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The key recommendations are as follows:

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·         Sulfonylurea drugs should be given to patients with type 2 diabetes who are unable to achieve glycemic control with metformin alone or who have contraindications to metformin use (strong recommendation, moderate-quality evidence).

·         Human insulin treatment should be introduced to patients with type 2 diabetes who do not achieve glycemic control with metformin and/or a sulfonylurea (strong recommendation, very-low-quality evidence).

·         If insulin is not appropriate to use, a dipeptidyl peptidase-4 inhibitor, a sodium-glucose cotransporter-2 inhibitor, or a thiazolidinedione may be added to the patient’s regimen (weak recommendation, very-low-quality evidence).

·         Human insulin can be used to manage glucose levels in type 1 diabetes and in type 2 diabetes when insulin is indicated (strong recommendation, low-quality evidence).

·         A long-acting insulin analog can be considered for managing glucose levels in type 1 or type 2 diabetes for adult patients who experience frequent severe hypoglycemia with human insulin (weak recommendation, moderate-quality evidence for severe hypoglycemia).

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These guidelines are intended to inform health systems with limited resources, taking into account costs and value alongside evidence-based care. “Type 2 diabetes is highly prevalent in most settings, and the increase in prevalence has been greatest in low- and middle-income countries in the past few decades,” note the authors.


Roglic G, Norris SL. Medicines for treatment intensification in type 2 diabetes and type of insulin in type 1 and type 2 diabetes in low-resource settings: synopsis of the World Health Organization guidelines on second- and third-line medicines and type of insulin for the control of blood glucose levels in nonpregnant adults with diabetes mellitus [published online September 4, 2018]. Ann Intern Med. doi:10.7326/M18-1149

This article originally appeared on Endocrinology Advisor