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🩺 Diabetes Drug Guide for GPs — Practical & Cost-Effective

📌 Quick Overview: Drugs to Know

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1️⃣ METFORMIN — Start Here for Almost Everyone

What it does

Who to start

• All newly diagnosed Type 2 DM unless contraindicated
• HbA1c any level — start at diagnosis alongside lifestyle changes
• Overweight/obese patients — extra benefit (mild weight loss)
• Patients with prediabetes at high risk of progression

Dose

Key rule: Always take with food to reduce GI side effects (nausea, diarrhea). Titrate slowly.

Contraindications

• eGFR < 30 — stop; eGFR 30–45 — reduce dose, monitor
• Severe liver disease
• Heart failure requiring hospitalization (relative)
• IV contrast — hold 48 hours before and after
• Alcoholism (lactic acidosis risk)

Cost

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2️⃣ SULFONYLUREAS — Add When Metformin Is Not Enough

Options (choose one)

Who to start sulfonylurea

• Metformin not tolerated or contraindicated
• Add to metformin when HbA1c target not met after 3 months
• Lean/normal-weight T2DM patients
• Cost-sensitive patients — extremely affordable

Key side effects

• Hypoglycemia — biggest risk; educate patient about symptoms
• Weight gain (1–2 kg)
• Avoid glibenclamide in elderly, CKD, or those skipping meals — use glipizide or gliclazide instead

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3️⃣ PIOGLITAZONE — Third Line or Add-On

What it does

Who to use it in

• Metformin + sulfonylurea still not enough
• Patients with significant insulin resistance (metabolic syndrome, fatty liver)
• Cannot use insulin yet

Dose

• Start 15 mg once daily
• Can increase to 30 mg, then 45 mg once daily (max)
• Take any time of day, with or without food

Contraindications / Cautions

• Heart failure (fluid retention) — avoid
• Osteoporosis / fracture risk (women especially) — caution
• Bladder cancer history — avoid
• Liver disease — check LFTs before starting
• Can cause edema and weight gain

Cost

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4️⃣ ACARBOSE — Useful for Postprandial Spikes

What it does

Who to use it in

• Patients with high postprandial glucose but near-normal fasting
• When you want to avoid hypoglycemia (does not cause hypo on its own)
• Can combine with anything

Dose

• Start 25 mg three times daily with first bite of each meal
• Increase gradually to 50 mg TDS, then up to 100 mg TDS (max)

Side effects

• Bloating, flatulence, diarrhea — very common, especially on starchy/high-carb diet
• Tell patients: GI side effects reduce if they reduce carbs
• No hypoglycemia when used alone

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5️⃣ REPAGLINIDE — For Irregular Meal Patterns

What it does

Who to use it in

• Patients who skip meals or have irregular eating schedules
• Sulfonylurea not suitable
• CKD patients (safer than glibenclamide — mostly hepatically cleared)

Dose

• Start 0.5 mg before each main meal
• Increase to 1–2 mg before each meal (max 4 mg/dose, 16 mg/day)
• Only take when eating a meal — skip if skipping meal

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6️⃣ INSULIN — For Advanced Disease or Failures

When to start insulin

• HbA1c very high (>10–12%) at diagnosis — start insulin directly
• Type 2 DM failing 2–3 oral agents
• Type 1 DM — mandatory from day one
• Pregnancy
• Hospitalization, surgery, acute illness
• Kidney or liver failure making oral drugs unsafe

Practical insulin choices for GP

Cost tip: NPH + Regular insulin are the cheapest and widely available in generic/government supply. Glargine is more expensive but less hypo risk.

Titration rule (simple)

• Check fasting blood glucose every 3 days
• If fasting BG > 7 mmol/L → increase bedtime NPH by 2 units
• Continue until fasting BG is 4–7 mmol/L

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📊 COMBINATION STRATEGIES — Step by Step

STEP 1: Diagnosis
    → Start METFORMIN + Lifestyle (diet, exercise, weight loss)
    → Target HbA1c in 3 months

STEP 2: HbA1c still above target after 3 months
    → Add SULFONYLUREA (glimepiride or gliclazide — cheapest add-on)
    
STEP 3: Still not at target
    → Add PIOGLITAZONE  OR  start BEDTIME NPH INSULIN
    
STEP 4: Insulin required
    → Bedtime NPH + continue metformin
    → Progress to twice-daily premixed (70/30) if needed
    → Stop sulfonylurea when on full insulin (hypoglycemia risk)

Combinations that WORK WELL together

Combinations to AVOID

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👥 WHICH PATIENTS — WHICH DRUG

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💰 COST-EFFECTIVE PRIORITY LIST

1. Metformin — cheapest, safest, start always
2. Glimepiride / Gliclazide — cheap, effective, widely available
3. NPH + Regular insulin — cheapest insulin option
4. Pioglitazone — moderately priced generic
5. Acarbose — moderate cost, useful adjunct
6. Repaglinide — slightly pricier but valuable in specific cases

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⚠️ KEY MONITORING POINTS

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🎯 HbA1c Targets

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