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EVIDENCE IN PATIENT CARE
in combination with sulfonylureas. DPP-4
inhibitors were well tolerated, with no
increased risk of gastrointestinal adverse
effects (nausea, vomiting, abdominal
pain and diarrhoea). The incidence of
gastrointestinal adverse effects was
higher with metformin and GLP-1
agonists. In this analysis, the risk of
nasopharyngitis, upper respiratory tract
infection and urinary tract infection did
not differ between DPP-4 inhibitors and
The DPP-4 inhibitors and exenatide are
attractive options in people with diabetes
requiring dual or triple therapy with
metformin and/or sulfonylurea treatment
to control hypoglycaemia because they
improve blood glucose without weight gain
and less hypoglycaemia than insulins. In
the case described at the start of this article,
a number of options could be considered,
including the incretin-based therapies,
as it appears that optimum therapy with
metformin and/or sulfonylureas has not
provided adequate glycaemic control.
The available options to consider include
insulin, thiazolidinediones, acarbose or
incretin-based therapies. Table 2 provides
an overview of the benefits and limitations
of the available options. An important
factor is the degree of beta-cell impairment,
which might be suspected when the
patient has long-standing disease and
increasing HbA1C despite good control
of lifestyle factors and maximal doses of
dual oral therapy with metformin and a
sulfonylurea. If this were the case, insulin
might provide the best option, although
weight gain may be problematic. Exenatide
may have similar effects on HbA1C to insulin
and lead to weight loss, but it results in
a higher incidence of adverse effects.
The ideal patient for whom incretin-based
therapies, particularly exenatide, could
be considered is obese, with elevated
glucose concentrations in spite of therapy
with oral hypoglycaemics.31 However, the
incretin-based therapies need continued
evaluation in terms of long term safety and
effect on diabetic complications, including
cardiovascular disease, to fully determine
their role among the well-established
therapies for type 2 diabetes. Whatever
option is chosen, it is important that the
significance of dietary modification and
exercise are reinforced.
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