medication choice brief from 10 steps article

Everyone newly diagnosed with type 2 diabetes should be offered a structured education programme along with locally appropriate weight management and exercise opportunities. If this fails to achieve a lowering of glycosylated haemoglobin (HbA_1c) to an individually tailored target, the latest National Institute for Health and Clinical Excellence (NICE) guidance (CG 66 and CG 87)^[13] supports the use of an increasingly complex cocktail of medications, including insulin. Certainly, triple therapy with metformin, a sulphonylurea and either a glitazone or a gliptin (dipeptidyl peptidase [DPP] IV inhibitor) should be used where appropriate. Many practices are achieving competence in using insulin regimens, which now have licences to be used with pioglitazone or sitagliptin, as well as metformin. The recently licensed injectible incretin mimetics (exanatide and liraglutide) may well become established primary care drugs in the future but for now they are probably best grouped with insulins, i.e. if you have the confidence, skills and knowledge to initiate insulin, you can certainly initiate incretin mimetics. The role of weight should always be borne in mind, and any intervention that lowers weight is likely to have a beneficial impact on diabetes control. Adjusting the energy balance (eat less, do more) is the cornerstone of weight management, but the use of weight-reducing drugs (orlistat is now the sole remaining licenced drug in this area) and bariatric surgery is recommended, the latter achieving normoglycaemia in over 50% of cases.^[14]