A patient with Type 2 diabetes may not respond to monotherapy with an oral hypoglycemic agent.



(1) the oral agent being used as initial monotherapy

(2) fasting glucose and hemoglobin A1c after a change in therapy

Initial Oral Agent

Second Oral Agent To Consider Adding


metformin, thiazolidinedione, DPP-4 inhibitor


sulfonylurea, thiazolidinedione, meglitinide, DPP-4 inhibitor


sulfonylurea, metformin, meglitinide


metformin, thiazolidinedione


In addition, encourage weight loss and exercise.


Targets for adequate control:

(1) fasting glucose < 140 mg/dL

(2) hemoglobin A1c < 8.0%


If targets are met then continue therapy.


If targets are not met then consider:

(1) adding a third oral agent

(1a) avoid using a meglitinide with a sulfonylurea

(1b) consider a GLP-1 mimetic in a patient taking metformin and a sulfonylurea

(2) adding an intermediate to long-acting insulin at bedtime (BIDO regimen)

(3) switching to insulin therapy alone

(4) referring to a diabetes specialist


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