Sulfonylureas as second line drugs in type 2 diabetes and the risk of cardiovascular and hypoglycaemic events: population based cohort study

The results of the observational study by Douros et al. analyzing the actual practice and outcomes highlight the value of metformin and indicate the need to use the effective hypoglycemic drug like sulfonylurea judiciously.1 The authors do mention the lack of details of drug doses and of reasons of switching to sulfonylurea as the limitation in study. However almost two thirds of the metformin initiators did not receive sulfonylurea in the study and the information, at least the names, of the various drugs prescribed to them would have further helped to analyze the practice especially for the purpose of making guidelines.

Regular physical activity and exercise and possible loss of excess body weight for as long as possible along with the continuation of the tolerated optimum dose of metformin are the cornerstones of therapy of type 2 diabetes. There is often need of controlling blood glucose immediately. Rescue therapy as and when required with sulfonylurea or insulin helps to control high blood glucose immediately and to taper off their dose later. Such tapering off helps to reduce the side effect of hypoglycemia which can also cause weight gain and difficulty in reducing weight or even accident and fall adding to all cause mortality. There are at least eight factors to consider while prescribing antihyperglycemic medications in type 2 diabetes, viz. efficacy, cost, hypoglycemia risks, effect on weight, cardiovascular benefits, convenience of administration, long-term safety profile, and effect on beta-cell workload.2 The aim in the management of hyperglycemia in type 2 diabetes is to normalize it with the help of antihyperglycemic medications avoiding hypoglycemia and helping the patient to continue regular physical activity and exercise and to reduce excess bodyweight for as long as possible. The accompanying editorial by McGowan and Roumie also concludes that higher HbA1c may have to be accepted to avoid hypoglycemia and adverse macrovascular outcomes.3 Whenever a hypoglycemic drug like sulfonylurea is required its dose should be dynamically managed for possible reduction to the minimal level and complete cessation.2

1. Douros A, Dell'Aniello S, Yu OHY, Filion KB, Azoulay L, Suissa S. Sulfonylureas as second line drugs in type 2 diabetes and the risk of cardiovascular and hypoglycaemic events: population based cohort study. BMJ. 2018;362:k2693.
2. Bhattarai MD. Principle of management of type 2 diabetes: From clinical, public health and research perspectives. In: Diabetes and Its Complications. Ahmed R. G. Ed. IntechOpen, DOI: 10.5772/intechopen.71193. Available from: https://www.intechopen.com/books/diabetes-and-its-complications/principl...
3. McGowan LDA, Roumie CL (Editorial). Sulfonylureas as second line drugs in type 2 diabetes. BMJ 2018;362:k3041.