Note: there is a drug not mentioned in this list
- Mentioned in NICE 2009 guideline for T2DM but not in 2015.
- Insulin secretagogue, especially increases its secretion in response to glucose (first phase insulin release).
– Used in patients with unpredictable meal time.
– Good to tackle postprandial hyperglycemia (mild increase in fasting glucose level but disproportionately high A1C)
- Short duration of action (achieves peak plasma level in 1 hr & producing a rapid insulin-releasing effect that lasts for 3 hrs ) and hepatically excreted (T1/2 = 1 hr)
– Can be used in renally-impaired patients
– Lesser hypoglycemia (as it is short acting and increases insulin secretion IN RESPONSE to glucose, unlike sulfonylureas)
Rational of combination therapy
- NICE suggests metformin + sulfonylurea or pioglitazone or DPP4i
- Common threshold to initiate combination therapy is when A1C >8%.
- With time, not only insulin resistance, there is loss of B-cell function as well (to abou 25% in 6 years).
- Primary objective is to tackle the problems of insulin resistance + deficiency.
– Metformin: insulin sensitizer
– Pioglitazone: insulin sensitizer
– Sulfonylurea: insulin secretagogue
– DPP4i: GLP-1 based (increases insulin secretion)