Glucagon-like peptide-1

Where the triple therapy with metformin and two other antidiabetic medicines is ineffective, not tolerated or contraindicated, the following treatment option should be considered:

Metformin, a sulfonylurea and a glucagon-like peptide-1 (GLP-1) for people who:

• Have a BMI of 35kg/m2 or over (adjusted accordingly for people from black, Asian and other minority ethnic groups) and have specific psychological or other medical problems associated with obesity, or
• A BMI lower than 35kg/m2 where insulin therapy would have specific implications on their occupation, or weight loss would benefit other obesity related co-morbidities.

SGLT-2 inhibitors

Treatment with SGLT-2 inhibitors may be appropriate and NICE recommends empaglifozin and canaglifozin be used in triple therapy as an option with the following combinations of medicines:

• Metformin and sulfonylurea
• Metformin and thiazolidinedione
• Dapaglifozin is only recommended in triple therapy in combination with metformin and a sulfonylurea.