If triple therapy with metformin and two other oral drugs is not effective, is not tolerated or is contra-indicated, consider combination therapy with metformin, a sulfonylurea and a GLP-1 mimetic for adults with type 2 diabetes who: In adults with type 2 diabetes, if metformin is contra-indicated or not tolerated, and if dual therapy with two oral drugs has not continued to control Hb A1c to below the person's individually agreed threshold for intensification, consider insulin-based treatment.
Consider relaxing the target Hb A1c level on a case-by-case basis, with particular consideration for people who are older or frail, for adults with type 2 diabetes: If adults with type 2 diabetes achieve an Hb A1c level that is lower than their target and they are not experiencing hypoglycaemia, encourage them to maintain it.
Be aware that there are other possible reasons for a low Hb A1c level - for example, deteriorating renal function or sudden weight loss.
Some people have had benefit with domperidone, erythromycin or metoclopramide.
The strongest evidence for effectiveness is for domperidone.
Treatment with combinations of medicines including SGLT2 inhibitors may be appropriate for some people with type 2 diabetes.
When starting insulin therapy in adults with type 2 diabetes, use a structured programme employing active insulin dose titration that encompasses: When starting insulin therapy in adults with type 2 diabetes, continue to offer metformin for people without contra-indications or intolerance.
See also the separate Antihyperglycaemic Agents used for Type 2 Diabetes and Insulin Regimens articles.
Offer standard-release metformin as the initial drug treatment for adults with type 2 diabetes.
History of heart failure/chronic kidney disease - SGLT-2 inhibitor or, if not suitable, GLP-1 mimetic.
(NB: in the UK, commencement of any SGLT-2 inhibitors is contra-indicated in patients with e GFR below 60.