Improving the Guidelines for Combination Therapy for Type II Diabetes Patients

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I have chosen the above topic because the guidelines are very vague in recommending this combination therapy even though we have clear cut guidelines recommending the use of individual agents in the treatment in Type II Diabetes patients. American diabetes association (1) guidelines recommend advising lifestyle modifications like healthy eating, increased physical activity and weight control, and if the patient fails to meet the target HbA1C levels on lifestyle changes, Metformin is added and over a period of three months, if the patient does not reach the target A1C levels, patient can be started on two drug combinations and we have several options to do this, from sulfonylureas, TZDs ,GLP-1 Analogues, DPP-4 inhibitors and insulin. A search of literature for this combination (2) shows that there are very few clinical studies conducted with the combination of GLP 1 analogues and Insulin and in these studies it was more common to find short-acting GLP-1 RA (exenatide twice daily, liraglutide once daily, lixesanatide once daily) treatment added to an existing insulin regimen (with or without concomitant OAMs) rather than insulin added to existing GLP-1 RA therapy.
I will limit the discussion here to only combination treatment of T2D with GLP-1 RA and basal insulin and would like to discuss the above topic under two headings-

1. Adding basal insulin to a patient who is already receiving OHAs + GLP-1 Analogues and discuss the results. What I do in my practice is
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