![]() Alternate to sulphonylurea if metformin-sulphonylura combination inadequate.Suggested uses for various blood glucose-lowering medicines in type 2 diabetes after metformin and sulphonylureas Tables 1 and 2 outline available drugs and suggested uses. The Australian Diabetes Society has recently published a position statement on this topic. Monotherapy and combination therapies (including insulin) outside the Pharmaceutical Benefits Scheme (PBS) indications and non-PBS listed drugs are not considered. This article discusses the use of glucose-lowering therapies. Ideally, new agents should be instituted and, if ineffective, stopped and an alternative agent used. Importantly, poor dietary adherence and inadequate physical activity can be major deterrents to achieving improved glucose control. It is likely that not all drugs will produce the same improvements in blood glucose control in all patients. The challenge is often to choose the option that best suits the patient and achieves a larger decline in HbA1c. The newer agents have not been tested in head-to-head trials. Confidence intervals for the decline in HbA1c, however, are 0–2%. ![]() Most pharmacological options will reduce glycosylated haemoglobin (HbA1c) by 0.5–1.0%, on average, either as monotherapy, compared to placebo, or in addition to metformin and or a sulphonylurea. 1 Choosing agents other than metformin or sulphonylureas is more difficult, apart from the use of insulin in patients who are clearly insulin-deficient. Sulphonylureas have a long history and their use is supported by outcome data from the UK Prospective Diabetes Study (UKPDS). The place of metformin as the drug of first choice is unquestioned. In recent years, pharmacological options for treating type 2 diabetes have expanded substantially.
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