Monotherapy

The first-line initial treatment that is tried is usually standard release metformin tablets unless contraindicated. The standard release dose should be gradually increased over several weeks to avoid gastrointestinal adverse effects but if the patient cannot tolerate the tablets, then modified release tablets should be considered.

If the patient cannot tolerate either form of metformin, or where metformin is contraindicated, the following alternatives should be tried unless they are contraindicated:

• A sulfonylurea
• Pioglitazone
• Dipeptidyl peptidase-4 inhibitors (DPP-4i)
• In May 2016 NICE recommended the SGLT-2 inhibitors (canagliflozin, dapagliflozin and empagliflozin) only if:
• A DPP-4i would otherwise be prescribed and
• A sulfonylurea or pioglitazone is not appropriate.