Diabetes Canada Clinical Practice Guidelines Expert Committee
Lorraine Lipscombe MD, MSc, FRCPC, Gillian Booth MD, MSc, FRCPC, Sonia Butalia MD, FRCPC, MSc,
Kaberi Dasgupta MD, MSc, FRCPC, Dean T. Eurich BSP, PhD, Ronald Goldenberg MD, FRCPC, FACE,
Nadia Khan MD, MSc, FRCPC, Lori MacCallum BScPhm, PharmD, CDE, Baiju R. Shah MD, PhD, FRCPC,
Scot Simpson BSP, PharmD, MSc
• Healthy behaviour interventions should be initiated in people newly diagnosed
with type 2 diabetes.
• In people with type 2 diabetes with A1C <1.5% above the person’s individualized
target, antihyperglycemic pharmacotherapy should be added if
glycemic targets are not achieved within 3 months of initiating healthy
• In people with type 2 diabetes with A1C ≥1.5% above target,
antihyperglycemic agents should be initiated concomitantly with healthy
behaviour interventions, and consideration could be given to initiating combination
therapy with 2 agents.
• Insulin should be initiated immediately in individuals with metabolic decompensation
and/or symptomatic hyperglycemia.
• In the absence of metabolic decompensation, metformin should be the initial
agent of choice in people with newly diagnosed type 2 diabetes, unless
• Dose adjustments and/or additional agents should be instituted to achieve
target A1C within 3 to 6 months. Choice of second-line antihyperglycemic
agents should be made based on individual patient characteristics, patient
preferences, any contraindications to the drug, glucose-lowering efficacy, risk
of hypoglycemia, affordability/access, effect on body weight and other factors.
• In people with clinical cardiovascular (CV) disease in whom A1C targets
are not achieved with existing pharmacotherapy, an antihyperglycemic agent
with demonstrated CV outcome benefit should be added to antihyperglycemic
therapy to reduce CV risk.
• In people without clinical CV disease in whom A1C target is not achieved
with current therapy, if affordability and access are not barriers, people with
type 2 diabetes and their providers who are concerned about hypoglycemia
and weight gain may prefer an incretin agent (DPP-4 inhibitor or GLP-1
receptor agonist) and/or an SGLT2 inhibitor to other agents as they improve
glycemic control with a low risk of hypoglycemia and weight gain.
• In people receiving an antihyperglycemic regimen containing insulin, in
whom glycemic targets are not achieved, the addition of a GLP-1 receptor
agonist, DPP-4 inhibitor or SGLT2 inhibitor may be considered before adding
or intensifying prandial insulin therapy to improve glycemic control with
less weight gain and comparable or lower hypoglycemia risk.