Published in IJCP October 2022
Choosing Glucose-lowering Therapy: A Collaborative Choice Model
October 13, 2022 | Sanjay Kalra, Saurabh Arora, Navneet Agrawal, Rajat Gupta, Suneet Verma, Nitin Kapoor
Diabetes & Endocrinology


Diabetes care is challenging, and the increasing number of available therapeutic options has made it even more complex. Moreover, with an increasing prevalence across the world, it needs to be managed right from the primary care level to a quaternary care hospital. This calls for an easy-to-use algorithm that can be used by a general practitioner, who is often the first contact of a patient to manage diabetes in many countries. There are multiple models to assist in choice of pharmacotherapy, and these have evolved over time. We propose a user-friendly collaborative choice, as an aid to clinical decision-making. This alliterative framework supplements and strengthens existing guidance, by creating a comprehensive, yet simple, thought process for the diabetes care professional.

Keywords: Pharmacotherapy, person-centered, type 2 diabetes

There are multiple algorithms and guides to choosing glucose-lowering therapy in persons with type 2 diabetes.1,2 Continued evolution of internationally accepted recommendations underscores the dynamic and flexible nature of diabetes practice. It is challenging, however, to condense a complex syndrome into just one or two tables, figures or graphs. This is evident in conventional and current attempts at ‘sanitizing’ choice of therapy.

While earlier models were criticized for3 being gluco­centric, modern rubrics have become cardiocentric and are equally tubular in their scope. It is heartening to note, however, that safety and economic considerations are now being highlighted in international guidelines.


We have earlier proposed vasocentric and metabolic fulcrum-based frameworks4,5 to help in clinical decision-
making in diabetes. Classification of glucose-lowering therapies have also been crafted,6,7 to make them easier to understand. We now share a chart, which simplifies the thought process behind choice of glucose-lowering therapy. The user-friendly format lists 4 domains, all alliteratively named, which must be kept in mind, while deciding treatment. The word ‘collaborative’ is used in the title to remind ourselves that the person living with diabetes is an active participant in his/her their treatment.

The hierarchy of the “C chart” (choice chart), as we term it, corresponds broadly to the conventional order of patient evaluation (history taking, examination, investigations), and assesses both biomedical and psychosocial issues. It retains person-centricity and pragmatism in its ethos, by considering habits, challenges/constraints and also analyzing the diabetes care ecosystem that he/she/they live in.

Table 1 presents the model that can act as a tool in clinical practice. This chart supplements existing guidance, and makes diabetes care easier, more efficient and perhaps more enjoyable, for practitioners and students alike.

Table 1. Glucose-lowering Therapy in Type 2 Diabetes: The C Chart for Collaborative Choice




Complaints and concerns

Acknowledge complaints and concerns

Endeavor to address them

Trivialize complaints and concerns

Ignore them while choosing treatment

Complication and comorbidities

Institute appropriate therapy

Refer if indicated

Ignore red flags

Create iatrogenic complications with inappropriate therapy

Concomitant medication and culinary pattern

Take detailed history

Optimize diet and lifestyle

Neglect to ask about complementary therapy

Use regimes that are discordant with diet

Cost constraints and care ecosystem

Be mindful of bio­psychosocial health

Be pragmatic in delivery of care

Take unilateral decisions

Be dismissive of patient’s reality


The C chart for collaborative choice is a simple model to remind a treating clinician about the different domains of patient characteristics that need to be kept in consideration before finalizing the prescription. This model can be applied across different types of diabetes, ethnicities and socioeconomic status of people living with diabetes.


  1. Kalra S, Dhar M, Afsana F, Aggarwal P, Aye TT, Bantwal G, et al. Asian Best practices for Care of Diabetes in Elderly (ABCDE). Rev Diabet Stud. 2022;18(2):100-34.
  2. Aswathy S, Unnikrishnan AG, Kalra S. Effective management of type 2 DM in India: looking at low-cost adjunctive therapy. Indian J Endocrinol Metab. 2013;17(1):149-52.
  3. Punyani H, Lathia T, Kalra S. Approach to glucose control: The SECURE model. J Pak Med Assoc. 2021;71(1(A)):168-9.
  4. Kalra S, Bhattacharya S, Kapoor N. Glucagon-like peptide 1 receptor agonists (GLP1RA) and sodium-glucose co-transporter-2 inhibitors (SGLT2i): making a pragmatic choice in diabetes management. J Pak Med Assoc. 2022;72(5):989-90.
  5. Kalra S, Gupta Y. Choosing injectable therapy: the metabolic fulcrum. J Pak Med Assoc. 2016;66(7):908-9.
  6. Kalra S, Shaikh S, Priya G, Baruah MP, Verma A, Das AK, et al. Individualizing time-in-range goals in management of diabetes mellitus and role of insulin: clinical insights from a multinational panel. Diabetes Ther. 2021;12(2):465-85.
  7. Kalra S, Bantwal G, Sahay RK, Bhattacharya S, Baruah MP, Sheikh S, et al. Incorporating Integrated Personalised Diabetes Management (iPDM) in treatment strategy: a pragmatic approach. Indian J Endocrinol Metab. 2022;26(2):106-10.