Pharmacological management of type 2 diabetes

The choice, order and combination of medicines are based on evidence, risk of adverse effects and patient choice.1

  • Metformin is the drug of first choice for people with type 2 diabetes who have inadequate glycaemic control after 3 months of making lifestyle changes. Sulfonylurea may be used if metformin cannot be tolerated.1-3
  • Only add another medicine if target blood glucose levels are not achieved after titrating metformin (or a sulfonylurea) to the highest tolerated dose for 3–6 months.1
  • Always check and address other factors that may interfere with control before adding a second or third glucose-lowering medicine e.g. poor self-management of diet and fitness, nonadherence to medicine, medicines that increase blood glucose levels such as steroids.1
  • Historically the preferred medicine to add as second-line therapy has been a sulfonylurea, as it is the most cost effective and is supported by decades of clinical experience.1,2 However, alternative approaches include introducing one other oral glucose-lowering medicine (thiazolidinedione, DPP4 inhibitor, acarbose, SGLT2 inhibitor) or if the patient is willing to self-inject, insulin or a GLP1 agonist.1 Consider this in addition to lifestyle measures, adherence to medicines and dose titration.1
  • Insulin is the preferred drug for people with inadequate glycaemic control despite taking maximally tolerated doses of oral glucose-lowering agents.1 Anticipate and proactively address hesitation to beginning insulin therapy.1
References
  1. The Royal Australian College of General Practitioners and Diabetes Australia. General practice management of type 2 diabetes – 2014-2015. 2014. [Online] (accessed  6 August 2015).
  2. Endocrinology Expert Group. Therapeutic Guidelines: Endocrinology. eTG complete. Version 5. Therapeutic Guidelines Limited: Melbourne, 2016. [Online] (accessed 19 May 2016).
  3. Australian Medicines Handbook 2015. Adelaide, Australian Medicines Handbook Pty Ltd, 2014. [Online].
  4. Nathan DM, Buse JB, Davidson MB, et al. Medical management of hyperglycaemia in type 2 diabetes mellitus: a consensus algorithm for the initiation and adjustment of therapy: a consensus statement from the American Diabetes Association and the European Association for the Study of Diabetes. Diabetologia 2009;52:17–30. [PubMed]
  5. Bennett WL, Maruthur NM, Singh S, et al. Comparative effectiveness and safety of medications for type 2 diabetes: an update including new drugs and 2-drug combinations. Ann Intern Med 2011;154:602–13. [PubMed]
  6. National Vascular Disease Prevention Alliance. Guidelines for the management of absolute cardiovascular disease risk. 2012. [Online] (accessed 15 July 2014).