Position of Sulfonylureas in the Current ERA: Review of National and International Guidelines

Abstract

Sulfonylureas (SUs) are one of the commonly prescribed oral anti-hyperglycemic agents (AHA) in low- and middle-income countries (LMICs), either in combination with metformin therapy or alone. However, concern about cardiovascular safety has limited the use of SUs in the management of type 2 diabetes mellitus (T2DM). Additionally, lack of uniformity in the national and international guidelines regarding the positioning of SUs in the management of diabetes has also been reported. The objective of this review was to assess the various national and international guidelines on diabetes management and understand the recommendations specific to SUs in various scenarios. A total of 33 national and international guidelines on the management of T2DM published in English were evaluated. These guidelines have considered the latest evidence and suggest the use of certain second-generation SUs as second-line therapy or in combination with other AHAs in select population and specific scenarios. Identification of the appropriate population, classification based on underlying risk, thorough assessment of the comorbid conditions, and a step-wise approach for the selection of appropriate SUs is essential for the effective management of T2DM. Additionally, cost-to-benefit ratio should be considered, particularly in LMICs, and SUs could continue to play an important role in such settings.

Keywords: Sulfonylureas; national and international guidelines; type 2 diabetes.

Figure 1.

Guidelines recommending different oral AHAs as second-line therapy in T2DM.^3,5,- AGI, alpha-glucosidase inhibitors; DPP-4i, dipeptidyl peptidase 4 inhibitor; SGLT-2i, sodium–glucose transport protein 2 inhibitor; SU, sulfonylurea; TZD, thiazolidinediones. Guidelines: International: American Diabetes Association (ADA), European Association for the Study of Diabetes (EASD), International (IDF), World Health Organization (WHO), American Association of Clinical Endocrinologists (AACE), National Institute for Clinical Excellence (NICE), International Society for Pediatric and Adolescent Diabetes (ISPAD); National: India, Nepal, Bangladesh, Pakistan, Sri Lanka, Canada, Colombia, Australia, Egypt, Nigeria, Uganda, Middle East and North Africa, China, Korea, Singapore, Austria, Belgium, Germany, Greece, Hungary, Israel, Italy, Netherlands, Poland, Portugal, and Romania.