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● Highly motivated patients with near-target HbA1c values should initially try lifestyle changes for 3-6 months before commencing with pharmacotherapy.
● Metformin is the drug of choice in the absence of contraindications, most importantly of risk factors for lactate acidosis. Titrate metfomin gradually to reduce gastro-intestinal side-effects.
● The most affordable and clinically validated metformin alternatives are glibenclamide and insulin. The much more costly pioglitazone, DPP-4 inhibitors, and GLP-1 receptor agonists are the best metformin alternatives if the primary goal is to avoid hypoglycemia and the latter two if the goal is to reduce weight.
● In the aged, the choice of antihyperglycemic agent should primarily focus on drug safety, trying to avoid hypoglycemia (sulfonylurea, insulins), heart failure (pioglitazone), renal dysfunction (metformin), bone fractures (pioglitazone), and drug-drug interactions resulting from treatments of comorbidities.
● Combining two antidiabetic drugs at diagnosis may be justified in patients with HbA1c values of 9.0%, with long-acting insulin (insulin glargine) recommended at HbA1c >10.0%.