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2499 pages added, reviewed or updated during the last month (last updated: 18/4/2021)

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NICE guidance - sulfonylurea in type 2 diabetes

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In the latest NICE guidance sulphonylureas (SU) are a treatment option in both possible treatment arms (metformin tolerant or metformin intolerant) (1):

If metformin tolerant then (1):

  • metformin is first line therapy and titrated up to usual maximum dose of 1g bd

  • an SU is an option for first intensifcation of therapy if, despite treatment with metformin, the HbA1c is > 58 (7.5%)

  • if an SU has not been used in the first intensification of therapy then it is an option for the second intensification
    • if HbA1c rises to 58 mmol/mol (7.5%)
      • metformin, a DPP-4 inhibitor (gliptin) and an SU, or,
      • metformin, pioglitazone and an SU , or,
      • metformin, an SU, and an SGLT-2 inhibitor

If metformin intolerant then (1):

  • SU is an option for first line therapy as is pioglitazone therapy or therapy with a sulphonylurea

  • SU is an option for dual therapy as first intensification of therapy if after initial therapy the HbA1c is > 58 (7.5%)
    • pioglitazone and an SU
    • DPP-4i and an SU

From previous guidance (2):

  • a sulfonylurea should be considered as an option for first-line glucose-lowering therapy if:
    • person is not overweight
    • person does not tolerate metformin (or it is contraindicated) or
    • a rapid response to therapy is required because of hyperglycaemic symptoms
  • a sulfonylurea should be added as second-line therapy when blood glucose control remains or becomes inadequate with metformin
  • continue with a sulfonylurea if blood glucose control remains or becomes inadequate and another oral glucose-lowering medication is added
  • a sulfonylurea with a low acquisition cost (but not glibenclamide) should be prescribed when an insulin secretagogue is indicated
  • when drug concordance is a problem, offer a once-daily, long-acting sulfonylurea
  • a person being treated with an insulin secretagogue, particularly if renally impaired, should be educated about the risk of hypoglycaemia
  • consider offering a rapid-acting insulin secretagogue to a person with an erratic lifestyle


  1. NICE (May 2008). Management of type 2 diabetes.
  2. NICE (December 2015). Type 2 diabetes in adults: management

Last reviewed 03/2021