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Most experts agree that lifestyle modifications and metformin (Glucophage, and others) should be used first to treat patients with type 2 diabetes.1 If metformin alone fails to control hyperglycemia, there is no general agreement on which drug should be added next. A recent article in The Medical Letter offered some support for a sulfonylurea.2 Three recent trials published in The Lancet favored the long-acting basal insulin glargine, the glucagon-like peptide (GLP-1) analog exenatide, and the dipeptidyl peptidase-4 (DPP-4) inhibitor linagliptin, respectively.3,4,5 Some of the advantages and disadvantages of these and other available agents are listed in Table 1.
RECOMMENDATIONS — When metformin does not adequately control hyperglycemia, addition of a sulfonylurea appears... more
3. P Aschner et al. Insulin glargine versus sitagliptin in insulin-naive patients with type 2 diabetes mellitus uncontrolled on metformin (EASIE): a multicentre, randomised open-label trial. Lancet 2012; 379:2262.
4. B Gallwitz et al. Exenatide twice daily versus glimepiride for prevention of glycaemic deterioration in patients with type 2 diabetes with metformin failure (EUREXA): an open-label, randomised controlled trial. Lancet 2012; 379:2270.
5. B Gallwitz et al. 2-year efficacy and safety of linagliptin compared with glimepiride in patients with type 2 diabetes inadequately controlled on metformin: a randomised, double-blind, non-inferiority trial. Lancet 2012; June 27 (epub).