- WHO guidelines are aimed at adults with either type 1 diabetes (T1D) or type 2 diabetes (T2D) in low-resource settings worldwide and disadvantaged populations in high-income countries.
- Give a sulfonylurea to patients with T2D who do not achieve glycemic control with metformin alone or who have metformin contraindications.
- Introduce human insulin to patients with T2D who do not achieve glycemic control with metformin and/or a sulfonylurea.
- If insulin is unsuitable, a dipeptidyl peptidase-4 (DPP-4) inhibitor, a sodium-glucose cotransporter-2 inhibitor (SGLT-2i), or a thiazolidinedione (TZD) may be added.
- Use human insulin in adults with T1D and with T2D for whom insulin is indicated.
- Consider long-acting insulin analogues in adults with T1D or T2D who have frequent severe hypoglycemia with human insulin.
American College of Physicians editorial commentary
- “Although sulfonylureas have been used for decades and their long-term safety has been established, we…worry about the cumulative effect of hypoglycemia.”
- “The decision to name sulfonylureas as the single best second-line agent largely reflects the prioritization of cost and the recognition that WHO guidelines must apply to low-resource settings.”
- “Another consideration…is emerging evidence of potential additional benefits for some agents” such as cardiovascular benefit with some SGLT-2is.