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The last decade has witnessed the introduction of several new drug classes and drug formulations that effectively reduce hyperglycaemia in type 2 diabetes. Expansion of drug choices is set against a background of increasing awareness of the progressive nature of type 2 diabetes. The next decade will see emergence of new therapies with novel modes of action further broadening the palate of agents available for clinical use. This expansion will enable tailoring of therapy in diabetes based on individual response to a particular drug, as well as any specific side-effects arising from treatment.Consensus guidelines have now incorporated metformin as the first choice oral agent, along with appropriate dietetic and lifestyle advice, in the early management of hyperglycaemia in type 2 diabetes.1 It has also a role in preventing people with impaired glucose tolerance (IGT) progressing to type 2 diabetes.2 Metformin acts by reducing gluconeogenesis (elevated in type 2 diabetes) and improving insulin sensitivity. This is the only biguanide in current practice. Patients can experience significant gastrointestinal side effects which may be ameliorated by switching from immediate-release preparations to newer delayed-release formulations.Recent NICE guidance promotes the use of sulphonylureas as second-line therapy.3 These agents act by directly stimulating insulin secretion by beta cells in a nonglucose dependent manner and can cause, in some individuals, weight gain and hypoglycaemia.The place of thiazolidindiones — the ‘TZDs’ or ‘glitazones’ — has come into question following the publication of a meta-analysis showing an excess of myocardial infarctions in patients treated with rosiglitazone.4 As insulin sensitisers, whose action is mediated through peroxisome proliferator-activated receptor γ (PPARγ) activation, these drugs showed much promise in terms of durability of effect and, in those who respond well to the agent, useful reductions in HbA1c. Pioglitazone has been shown to have beneficial effects …

Current, new, and emerging therapies for managing hyperglycaemia in type 2 diabetes