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The pandemic of type 2 diabetes necessitates early and effective treatment to delay or prevent micro- and macrovascular complications associated with diabetes (1–3). However, the majority of patients with type 2 diabetes do not reach their therapeutic goals as a result of insufficient treatment. The cardiovascular mortality risk is increased, and 75% of patients with type 2 diabetes die of cardiovascular events. Type 2 diabetes is the main cause of end-stage renal disease and dialysis in many countries (4). The vascular complication risk can be lowered by improved metabolic control (2,3). However, further important treatment goals such as body weight reduction or the prevention of hypoglycemia are seldom accomplished.In type 2 diabetes, a stepwise escalation of therapy is suggested along the course and progression of the disease. Metformin is widely accepted as the first-line therapy, but owing to partly lacking evidence, with regard to further therapeutic steps there is room for various individual treatment choices. Recently, a Position Statement by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) tried to value and position second- and third-line therapies according to their efficacy, side effects, hypoglycemia incidence, body weight development, and costs (5).Adding another oral agent to metformin in order to escalate therapy when necessary presently gives the choice of sulfonylureas, glinides, dipeptidyl peptidase (DPP)-4 inhibitors, pioglitazone, and α-glucosidase inhibitors. The efficacy of these agents as add-on medication to metformin is only modest, and on average an additional HbA1c reduction of ~0.5–1% can be expected. Furthermore, the treatment with sulfonylureas, glinides, and pioglitazone is associated with body weight gain. Sulfonylurea and glinide therapy is also associated with a risk of hypoglycemia. α-Glucosidase inhibitors predominantly lower postprandial hyperglycemia and therefore show less HbA1c reduction in most studies. …

diabetes care

How Do We Continue Treatment in Patients With Type 2 Diabetes When Therapeutic Goals Are Not Reached With Oral Antidiabetes Agents and Lifestyle? Incretin versus insulin treatment