Drug treatment

Recommendations in this section that cover dipeptidyl peptidase?4 (DPP?4) inhibitors, glucagon?like peptide?1 (GLP?1) mimetics and sulfonylureas refer to each of these groups of drugs at a class level.

For adults with type 2 diabetes, discuss the benefits and risks of drug treatment, and the options available. Base the choice of drug treatment(s) on:
the effectiveness of the drug treatment(s) in terms of metabolic response

the person’s individual clinical circumstances, for example, comorbidities, risks from polypharmacy

the person’s individual preferences and needs

the licensed indications or combinations available

cost (if 2 drugs in the same class are appropriate, choose the option with the lowest acquisition cost).

Initial drug treatment

1.Offer standard-release metformin as the initial drug treatment for adults with type 2 diabetes.
Gradually increase the dose of standard?release metformin over several weeks to minimise the risk of gastrointestinal side effects in adults with type 2 diabetes.

If an adult with type 2 diabetes experiences gastrointestinal side effects with standard?release metformin, consider a trial of modified?release metformin.

In adults with type 2 diabetes, review the dose of metformin if the estimated glomerular filtration rate (eGFR) is below 45 ml/minute/1.73m2:
Stop metformin if the eGFR is below 30 ml/minute/1.73m2.

Prescribe metformin with caution for those at risk of a sudden deterioration in kidney function and those at risk of eGFR falling below 45 ml/minute/1.73m2.

In adults with type 2 diabetes, if metformin is contraindicated or not tolerated, consider initial drug treatment with:
a dipeptidyl peptidase?4 (DPP?4) inhibitor or

pioglitazone or a sulfonylurea.

In adults with type 2 diabetes, do not offer or continue pioglitazone if they have any of the following:
heart failure or history of heart failure

hepatic impairment

diabetic ketoacidosis

current, or a history of, bladder cancer

uninvestigated macroscopic haematuria.

.First intensification of drug treatment

In adults with type 2 diabetes, if initial drug treatment with metformin has not continued to control HbA1c to below the person’s individually agreed threshold for intensification, consider dual [/color]therapy with:

metformin and a DPP?4 inhibitor or

metformin and pioglitazone or

metformin and a sulfonylurea.

Treatment with combinations of medicines including sodium–glucose cotransporter 2 (SGLT?2) inhibitors may be appropriate for some people with type 2 diabetes; check with author for these newer treatment modalities.

G MOHAN. tbc

Second intensification of drug treatment

In adults with type 2 diabetes, if dual therapy with metformin and another oral drug, has not continued to control HbA1c to below the person’s individually agreed threshold for intensification, consider either:
triple therapy with:

metformin, a DPP?4 inhibitor and a sulfonylurea or

metformin, pioglitazone[4]and a sulfonylurea or

starting insulin-based treatment – see below.

If triple therapy with metformin and 2 other oral drugs (see recommendation 1.6.27) is not effective, not tolerated or contraindicated, consider combination therapy with metformin, a sulfonylurea and a glucagon?like peptide?1 (GLP?1) mimetic for adults with type 2 diabetes who:

have a BMI of 35 kg/m2 or higher (adjust accordingly for people from black, Asian and other minority ethnic groups) and specific psychological or other medical problems associated with obesity or

have a BMI lower than 35 kg/m2and:

for whom insulin therapy would have significant occupational implications or

weight loss would benefit other significant obesity?related comorbidities.

Only continue GLP?1 mimetic therapy if the person with type 2 diabetes has had a beneficial metabolic response (a reduction of at least 11 mmol/mol [1.0%] in HbA1c and a weight loss of at least 3% of initial body weight in 6 months).

In adults with type 2 diabetes, if metformin is contraindicated or not tolerated, and if dual therapy with 2 oral drugs has not continued to control HbA1c to below the person’s individually agreed threshold for intensification,
consider insulin?based treatment
In adults with type 2 diabetes, only offer a GLP?1 mimetic in combination with insulin with specialist care advice and ongoing support from a consultant?led multidisciplinary team.
Treatment with combinations of medicines including SGLT?2 inhibitors may be appropriate for some people with type 2 diabetes;

canagliflozin in combination therapy for treating type 2 diabetes, dapagliflozin in combination therapy for treating type 2 diabetes and empagliflozin in combination therapy for treating type 2 diabetes- check with author on these newer drugs( prons and cons) particularly in the Asian populations.

G Mohan. To follow -detail of Insulin based treatments.