If the fasting blood glucose level is above 180 mg/dL, the patient urgently needs either a sulfonylurea to increase insulin secretion or insulin itself. If the blood glucose level has not improved after a week of taking a sulfonylurea and adhering to dietary recommendations, I might start treatment with a drug that would help gluconeogenesis, glycogenolysis, or insulin sensitivity to improve both preprandial and postprandial glucose levels.
If the patient is obese with a fasting blood glucose level below 180 mg/dL, I may begin with metformin. Because this is a referral clinic, most of my patients are already taking three drugs and insulin when they come to me. If they are not taking insulin, I opt for treatment with three drugs instead of insulin if possible because Latino patients are often reluctant to take insulin. Often a combination of a sulfonylurea, a thiazolidinedione, and metformin is effective.
Glimepiride is our sulfonylurea of choice because we participated in clinical trials and found it very effective. Also, it can be taken just once a day, which is important for adherence, and, as long as it’s taken every 24 hours, it maintains steady-state glucose levels without causing hypoglycemia. We’ve also found that patients who do need insulin can take lower doses if they are taking glimepiride.