Management of the adult onset diabetic with sulfonylurea drug failure

Abstract

With apparent failure of SU drug therapy, the management of NIDDM patients becomes even more challenging. The following sequence of actions is recommended. 1. Situational dietary noncompliance (eg, a prolonged vacation or a recent period of family or occupational stress) should be treated first by renewed regular contacts with the dietician. 2. Occult infection, hyperthyroidism, and prescription of hyperglycemic drugs by another physician should be ruled out. 3. If true secondary failure exists, the patient should be started on insulin therapy alone and the program optimized to lower fasting plasma glucose to less than 140 mg/dL (8 mM) and subsequently postprandial glucose levels to less than 200 mg/dL (11 mM). NPH, Lente, or Ultralente insulin given only in the evening may be considered for patients with some indication of preservation of postprandial insulin release. 4. If the patient refuses to accept insulin therapy initially, a temporary switch to another second generation SU drug may be tried, primarily to convince the patient that oral drugs alone are inadequate. 5. If optimized insulin therapy fails to achieve therapeutic goals, if multiple insulin injections are not feasible, or if goals are achieved only at the expense of very large insulin doses, then combination therapy with an SU drug may be tried.