diabetes escalation

Question 1

First treatment intensification – (See Appendix 2)8,9

Answer 1

Metformin in combination with another antidiabetic:
Metformin + DPP-4 inhibitor
Metformin + pioglitazone
Metformin + sulfonylurea
Metformin + SGLT-2 inhibitor (if sulfonylurea is contraindicated or not tolerated, or if the person is at significant risk of hypoglycaemia or its consequences)
Elderly pts or pts with renal impairment at risk of a hypo should be prescribed a shorter-acting sulfonylurea e.g., Gliclazide or Tolbutamide

Question 2

If Metformin is contraindicated or not tolerated, consider:

Answer 2

DPP-4 inhibitor + Pioglitazone or DPP-4 inhibitor + Sulfonylurea or Pioglitazone + Sulfonylurea

Question 3

If dual therapy not enough to control after this intensification, consider insulin
Second treatment intensification8,9
Triple therapy regimens:

Answer 3

Metformin + DPP-4 inhibitor + Sulfonylurea
Metformin + DPP-4 inhibitor + Pioglitazone
Metformin + Pioglitazone + Sulfonylurea
Metformin + Pioglitazone/Sulfonylurea + SGLT-2 inhibitors canagliflozin or empagliflozin (Dapagliflozin is recommended only in combination with metformin and a sulfonylurea, not pioglitazone)
Metformin + DPP-4 inhibitor + SGLT-2 inhibitor ertugliflozin, only if sulfonylurea or pioglitazone is not appropriate.