What happens if after 6 months you are "still too high"

Then they look at the chart - they can then either increase your metformin (up to max levels) or add a "Tier 2 Treatment".

Tier 2 drugs belong to 3 main groups - DPP4's (Januvia/Tradjenta), GLP-1 (Ozempic/Trulicity) or SGLT-2 (Jardiance/Invokana). These are selected, again, based on your overall health - some have additional side benefits (as well as side effects) and the Doc can choose the type that "best suits you" since they all provide "similar" results.

Again, you will be monitored through future A1C tests. If your Tier 1 (diet/exercise/metformin) and Tier 2 (whatever class you were prescribed) is no longer "enough" then they will add a Tier 3 treatment.

Tier 3 drugs are the same as Tier 2, they will just select one that compliments whatever you are taking already. Again the experts have figured this out.

So if your Doc prescribed Ozempic as your tier 2 treatment the guideline tells them to add Jardiance or Invokana but "not" Januvia.

Again, you treating/prescribing Doc doesn't have to make any real decision and doesn't even have to know what the drugs are doing because the "guideline" written by the Type 2 experts have "figured it out".

Then as a last ditch effort to keep you off mealtime insulin they can try Sulfonylurea's (which rise to a Tier 2 treatment if the cost of meds is an issue) or another class, TZD's (which were mostly taken off the market due to nasty side effects but Avandia and Actos are still available).

And when everything else has failed (or the patient is not afraid of insulin) then Insulins are added - Basil's for fasting problems and Bolus for meal time problems.

It is just that easy. The guidelines tell them "what to do" with branches from the chart for patients with heart disease or kidney disease (or both) and those without insurance who are paying out of pocket or those that need to lose weight.

All the "thinking" is done for your Doc so even if you asked they likely couldn't tell you "why"....

The Guidelines are exactly that, "guidelines" not directives.

The last set were written in 2018 and were adopted by all the (western) Diabetes Associations (ADA, Diabetes UK/Canada/Australia and the EASD, the EU's version of the ADA).

Of course, since Doctors have to protect their own licences and are the ones on the hook for malpractice they are free to go "off label" as long as they are willing to accept the consequences of their actions.

But at least in the Diabetes world, even the guidelines give a ton of latitude for the Doc to consider.

I tried to condense a document that is close to 3 dozen pages into a couple of short posts so to say it was "massively paraphrased" would be an understatement.

There is treatment advice specifically for 1) diabetics that won't follow a program 2) those that are super keen to participate in their own treatment 3) those with heart failure 4) kidney failure 5) cardiovascular disease but not failing yet 6) both cardio and kidney issues 7) those you need to protect from low blood sugar 8) those that can't afford to gain weight 9) those that can't afford the "good meds"

And then there is considerations for age. Without being morbid if you diagnose a 70 year old with Type 2 maybe you don't have to protect against a complication that doesn't show up for 25 years.

They also spend some time talking about insulin because many Type 2's see it something to be avoided at all costs - so the guidelines basically tell doctors that if the patient won't take it, do what you can even though you know they are killing themselves.

Of course, some Doc's just have more experience then others and are comfortable colouring outside the lines a little based on their experience so will treat with different combinations.

Hey @A DiabetesTeam Member - yes, aside from the Insulins all of those drugs are only for Type 2's because they all pretty much work by regulating or inducing more of your own insulin production so effectively useless to those with Type 1, later stage LADA or the small percentage of Type 2's that are Severely Insulin Deficient (not caused by an auto-immune disease).

Unfortunately for that (group), Insulin replacement is the only real (treatment) at the moment. But given that many of the drugs I mentioned didn't even exist in theory 20 years ago, and the amount of Type 1 research going on, we might see alternate Type 1 treatments during our lifetimes (which would also benefit significantly progressed Type 2's as well).

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I never heard of any of those drugs you mentioned Graham maybe cause i am a Type 1 diabetic and have heard only of Metformin and that is it. I so agree with everything you said and my very own family doctor told me herself that she does not know what to do if my sugars go haywire of if my A1C is off so she sends me to someone else in town who has more knowledge of diabetes then herself but he is not an Endocrinologist. Sometimes us patients can learn more from others who have the disease then we can from our health care team. There are so many very knowledgeable people on this site like yourself and others who can better explain issues with diabetes and all that it entails and not make us feel bad about everything we are doing wrong in which case getting feed back like that only what? Causes us more stress which then helps us to gain more weight cause our sugars are once again out of whack and they figure that our issues is with food???? NOT ALWAYS....This has happened to me before many times over the years of my diagnosis always blaming my food consumption or the lack of exercise etc. Do they ask me now if I am exercising daily? NO....not like when i was bigger every time i went in there i dreaded it even got to a point where i refused to get on the scale cause i knew they would be so focused on that number that i would feel like crap once i left there. So i sometimes refused to get on it cause i didn't need the added stress to my diabetes on top of everything else i was going through at the time. Now there is no more talk about exercising.....no more talk about food consumption none of it meanwhile they have nooooo clue on how i lost weight on my own nor did they ask so i wont offer that info if i dont have too. I feel good....A1C has been in check but thyroid might be off again but there you have it. Keep on sharing Graham,Jo and others and thanks again for your wisdom, your diabetes experiences and all the information you all have shared. GOD BLESS EVERYONE. STAY SAFE.🥰

I'm actually surprised that people are averse to insulin. When I found out last May. I just assumed I would be on insulin forever. I am now on Lantus Trulicity and Metformin. Yes, would I like to not to have to take all this? Of course, but as of right now it's saving my life, and I'm all for that!!! Maybe because I grew up around my mother having to take 2 insulin shots a day that I am more comfortable with the idea of insulin. It's not terrible, the finger pricks are not terrible, in the scheme of my life, I'm going to do everything I can to help keep this under control. Unfortunately 6 weeks after being diagnosed as I was rolling along on a certain dosage of Lantus, the new PA who was supposed to be wonderful for diabetics dropped my Lantus from 26 to 14 (with many protestations from me) I thought it was too much too fast. I know she wanted to see if I could go lower, but I didn't think it was right. It wasn't and it sent me into weeks of trying to straighten it out. I was all over the place for a while. I was finally sent to an endocrinologist, who after one visit I have a lot of faith in. I was a little worried when adding the Trulicity but it seems like a great addition. It really is scary for us out there if the Dr or their assistants, even with the best of intentions have a hard time diagnosing us. .