James J. Chamberlain, MD; William H. Herman, MD, MPH; Sandra Leal, PharmD; Andrew S. Rhinehart, MD; Jay H. Shubrook, DO; Neil Skolnik, MD; Rita Rastogi Kalyani, MD, MHS
Acknowledgment: The authors thank Matt Petersen; Erika Gebel Berg, PhD; and Sarah Bradley for their assistance in the review and editing of this manuscript. The 2017 Standards of Medical Care in Diabetes was developed by the ADA Professional Practice Committee: William H. Herman, MD, MPH (Co-Chair); Rita Rastogi Kalyani, MD, MHS (Co-Chair); Andrea L. Cherrington, MD, MPH; Donald R. Coustan, MD; Ian de Boer, MD, MS; R. James Dudl, MD; Hope Feldman, CRNP, FNP-BC; Hermes Florez, MD, PhD, MPH; Suneil K. Koliwad, MD, PhD; Melinda Maryniuk, MEd, RD, CDE; Joshua J. Neumiller, PharmD; and Joseph I. Wolfsdorf, MB, BCh.
Disclosures: Dr. Chamberlain reports personal fees from Merck, Janssen Pharmaceuticals, and Sanofi outside the submitted work. Dr. Herman reports work on data monitoring committees for Lexicon Pharmaceuticals and Merck Sharp & Dohme outside the submitted work. Dr. Rhinehart reports personal fees from Sanofi, Janssen Pharmaceuticals, Boehringer Ingelheim, Novo Nordisk, Eli Lilly, Forest Pharmaceuticals, and AstraZeneca and other (employment and stock) from Glytec outside the submitted work. Dr. Skolnik reports personal fees and nonfinancial support from AstraZeneca and Sanofi and personal fees from Boehringer Ingelheim, Eli Lilly, and Teva outside the submitted work. Dr. Shubrook reports other from Lilly Diabetes (clinical trial and advisory board), AstraZeneca (clinical trial), Novo Nordisk (advisory board), and Takeda (clinical trial) outside the submitted work. Dr. Skolnik serves on the Primary Care Advisory Committee of the ADA. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M16-2937.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer and Johnson & Johnson.
Requests for Single Reprints: James J. Chamberlain, MD, St. Mark's Hospital and St. Mark's Diabetes Center, Internal Medicine at St. Mark's, 1160 East 3900 South, Suite 1200, Salt Lake City, UT 84124; e-mail, firstname.lastname@example.org.
Current Author Addresses: Dr. Chamberlain: St. Mark's Hospital and St. Mark's Diabetes Center, Internal Medicine at St. Mark's, 1160 East 3900 South, Suite 1200, Salt Lake City, UT 84124.
Dr. Herman: University of Michigan, 1000 Wall Street, Room 6108/SPC 5714, Ann Arbor, MI 48105.
Dr. Leal: SinfoníaRx, One East Toole, Tucson, AZ 85701.
Dr. Rhinehart: Glytec, 770 Pelham Road, Suite 210, Greenville, SC 29615.
Dr. Shubrook: Touro University College of Osteopathic Medicine, 1310 Club Drive, Admin and Faculty 1, Room 117, Vallejo, CA 94592.
Dr. Skolnik: Abington–Jefferson Health, Abington Family Medicine, 500 Old York Road, Suite 108, Jenkintown, PA 19046.
Dr. Kalyani: Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University, 1830 East Monument Street, Suite 333, Baltimore, MD 21287.
Author Contributions: Conception and design: J.J. Chamberlain, W.H. Herman, S. Leal, J.H. Shubrook, N. Skolnik, R.R. Kalyani.
Analysis and interpretation of the data: S. Leal.
Drafting of the article: J.J. Chamberlain, S. Leal, A.S. Rhinehart, J.H. Shubrook, N. Skolnik, R.R. Kalyani.
Critical revision of the article for important intellectual content: J.J. Chamberlain, W.H. Herman, S. Leal, R.R. Kalyani.
Final approval of the article: J.J. Chamberlain, W.H. Herman, S. Leal, A.S. Rhinehart, J.H. Shubrook, N. Skolnik, R.R. Kalyani.
Administrative, technical, or logistic support: J.J. Chamberlain.
Collection and assembly of data: J.J. Chamberlain, W.H. Herman, S. Leal, J.H. Shubrook.
The American Diabetes Association (ADA) annually updates the Standards of Medical Care in Diabetes to provide clinicians, patients, researchers, payers, and other interested parties with evidence-based recommendations for the diagnosis and management of patients with diabetes.
For the 2017 Standards, the ADA Professional Practice Committee updated previous MEDLINE searches performed from 1 January 2016 to November 2016 to add, clarify, or revise recommendations based on new evidence. The committee rates the recommendations as A, B, or C, depending on the quality of evidence, or E for expert consensus or clinical experience. The Standards were reviewed and approved by the Executive Committee of the ADA Board of Directors, which includes health care professionals, scientists, and laypersons. Feedback from the larger clinical community informed revisions.
This synopsis focuses on recommendations from the 2017 Standards about pharmacologic approaches to glycemic treatment of type 2 diabetes.
Table 1. Median Monthly Cost of Maximum Approved Daily Dose of Noninsulin Glucose-Lowering Agents in the United States*
Table 2. Median Cost of Insulins in the United States, Calculated as the AWP per 1000 Units of Specified Dosage Form/Product*
Antihyperglycemic therapy for type 2 diabetes: general recommendations.
The order in the chart was determined by historical availability and the route of administration, with injectables to the right; it is not meant to denote any specific preference. Potential sequences of antihyperglycemic therapy for patients with type 2 diabetes are displayed, with the usual transition moving vertically from top to bottom (although horizontal movement within therapy stages is also possible, depending on the circumstances). Adapted with permission from Inzucchi and colleagues (7). DPP-4-i = dipeptidyl peptidase-4 inhibitor; GI = gastrointestinal; GLP-1-RA = glucagon-like peptide-1–receptor agonist; GU = genitourinary; HbA1c = hemoglobin A1c; HF = heart failure; SGLT-2-i = sodium–glucose contransporter-2 inhibitor.
* See Dieuzeide and colleagues (21) for description of efficacy and cost categorizations.
† Usually a basal insulin (such as neutral protamine Hagedorn, glargine, detemir, or degludec).
Combination injectable therapy for type 2 diabetes.
Adapted with permission from Inzucchi and colleagues (7). GLP-1-RA = glucagon-like peptide-1–receptor agonist; HbA1c = hemoglobin A1c; SMBG = self-monitored blood glucose.
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Nagin Mavani, MD
May 17, 2017
Average wholesale price for Human Regular and NPH insulin is mentioned as $165 per vial of 1000 units. One brand of such insulin is available for direct purchase at $25 per vile from retail pharmacy at Walmart. Not available through prescription plans.
Chamberlain JJ, Herman WH, Leal S, Rhinehart AS, Shubrook JH, Skolnik N, et al. Pharmacologic Therapy for Type 2 Diabetes: Synopsis of the 2017 American Diabetes Association Standards of Medical Care in Diabetes. Ann Intern Med. ;166:572–578. doi: 10.7326/M16-2937
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Published: Ann Intern Med. 2017;166(8):572-578.
Published at www.annals.org on 14 March 2017
Cardiology, Coronary Risk Factors, Diabetes, Endocrine and Metabolism, Guidelines.
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