This algorithm is meant to provide a guide that reflects best practices, recognizing that RCT data are not available to guide every clinical decision. They reminded us of several principles to keep in mind: 1. Lifestyle modifications are essential for all patients with diabetes. 2. An A1c of 6.5% is recommended as the primary goal, which must be customized for the individual patient. 3. Combination therapy should involve classes of medications that have complementary mechanisms of action. 4. Safety and efficacy should be given higher priorities than cost of medications given thaf medications represent only a small part of the cost of care of diabetes. 5. The algorithm should be simple, help educate and guide therapy, be as specific as possible and provide guidance with prioritization and a rationale for selection of any particular regimen. Additionally, the panel recommends that: 1. “Rapid-acting insulin analogues are superior to “regular human insulin” and provide a better, safer alternative.” 2. “NPH insulin is not recommended. Use of NPH as a basal insulin has been superseded by the synthetic analogues....” The panel has succeeded in their goals; they have also generated controversy, which will help to spread the awareness and application of these guidelines. While we will argue some of their recommendations (ie types of insulin, how to do the combinations) the important point is that the guidelines provide a structure from which a clinician can attempt to determine effective strategies for getting glucose to goal. One controversial point is that metformin is not longer contraindicated in heart failure; the FDA removed this warning in Nov 2006. However, the panel has left this warning in place as it remains part of the lactic acidosis warning and needs to be a consideration when thinking about whether it is safe to prescribe metformin for a patient. Kittie Wyne, MD, PhD, FACE