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Treatment Overview

Oral Agents

These recommendations are presented in abbreviated form. Readers should refer to the text of the guideline document for a detailed discussion of each of the following topics.

Recommendations

1. Begin oral glucose-lowering drugs when lifestyle interventions alone are unable to maintain blood glucose control at target levels (see Glucose control levels). Maintain support for lifestyle measures throughout the periods of use of these drugs. Consider each initiation or dose increase of an oral glucose-lowering drug as a trial, monitoring the response in 2-6 months.
2. Begin with metformin unless evidence or risk of renal impairment, titrating the dose over early weeks to minimize discontinuation due to gastro-intestinal intolerance. Monitor renal function and risk of significant renal impairment (eGFR <60 ml/min/ 1.73 m²) in people taking metformin.
3. Use sulfonylureas when metformin fails to control glucose concentrations to target levels, or as a first-line option in the person who is not overweight.  Choose a drug of low cost, but exercise caution if hypoglycaemia may be a problem to the individual, including through renal impairment.  Provide education and, if appropriate, self-monitoring (see Self-monitoring) to guard against the consequences of hypoglycaemia. Once-daily sulfonylureas should be an available option where drug concordance is problematic. Rapid-acting insulin secretagogues may be useful as an alternative to sulfonylureas in some insulin-sensitive people with flexible lifestyles.
4. Use a PPAR-γ agonist (thiazolidinedione) when glucose concentrations are not controlled to target levels, adding it:
   
   • to metformin as an alternative to a sulfonylurea, or 
   • to a sulfonylurea where metformin is not tolerated, or
   • to the combination of metformin and a sulfonylurea.
   Be alert to the contra-indication of cardiac failure, and warn the person with diabetes of the possibility of development of significant oedema.
5. Use α-glucosidase inhibitors as a further option. They may also have a role in some people intolerant of other therapies.
6. Step up doses, and add other oral glucose-lowering drugs, at frequent intervals until blood glucose control is at target levels. Consider whether the rate of deterioration suggests insulin therapy will be needed early despite such measures.

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