Add Additional Oral Agents for Diabetes Sooner

Don't wait for a type 2 diabetes patient's blood glucose (HbA1c) to reach 7% before adding an additional oral drug therapy, counseled Stephen Clement, M.D., associate professor of medicine, Georgetown University, Washington, DC. "If you see in a series of office visits that a patient's HbA1c count is increasing and approaching 7, add an oral agent then and not at a later visit. In other words, don't wait for drug failure," he said.

Dr. Clement attempts to keep patients with type 2 diabetes at around 6% to slow disease progression, he said. He starts a patient on oral agents if exercise and diet are not adequately controlling blood sugar. Typically he uses metformin first, followed by a low dose sulfonylurea. If adequate control is not achieved, then a thiazolidinedione (TZD) can be added.

If a physician is not comfortable prescribing three oral drugs for patients who experience drug failure, then two agents are still better than one, said Clement. Clinicians should know that multiple drug therapy tends to prevent drug failure over time, he added.However, multiple drug therapy makes patient management "much more complicated than it was years ago," said Clement.

Some of the factors to consider with oral agents are gastrointestinal disturbance with metformin; weight gain and fluid retention with TZD's; and hypoglycemia with sulfonylureas. Contraindications include age and renal status for metformin and liver function for metformin and TZD's.

At some point, insulin will have to be added to an oral drug regimen, he said. "Eventually all type 2 diabetes will need insulin." Don't be afraid to start insulin early," he counseled.