First-line treatment: • diet therapy (especially if obese) • exercise program Most symptoms improve dramatically within 1 to 4 weeks on diet and exercise. 2 The secret to success is patient compliance through good education and supervision. The role of a diabetic education service, especially with a dietician, can be invaluable. If unsatisfactory control persists after 3-6 months, consider adding an oral hypoglycaemic agent (Table 17.4).
One of the sulfonylureas is usually selected: they are effective and have a low side-effect profile. They should be introduced with care and in a low dose in the elderly. Metformin, which has moderate antidiabetic potential, has less tendency to cause weight gain and is often used for obese patients. It tends to cause diarrhoea. Metformin can be added to a sulfonylurea.
When oral hypoglycaemics fail (secondary failure) the new agent acarbose can be added (it is also very effective first line). The classic symptoms of hyperglycaemia may be present but more commonly patients experience general disability. Approximately 30% of NIDDM patients eventually require insulin even after years of successful oral therapy.
Table 17.4 Commonly prescribed oral hypoglycaemic agents
Duration of action (hours)
Glibenclamide 16-24 Chlorpropamide 24-72
Maximum effective daily dose
850 mg, bd
Hypoglycaemia most common side effect.
Shorter acting sulfonylurea, e.g. tolbutamide, is preferred in elderly.
Longer acting potent ones cause troublesome hypoglycaemia in elderly.
Others: weight gain (common), rash and GIT (rare).
Usually reserved for obese but now first line.
GIT disturbances e.g. diarrhoea Avoid in cardiac, renal and hepatic disease
Lactic acidosis can be a serious complication.
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