Concise Review for Primary-Care Physicians
Pharmacologic Treatment Options for
Non-Insulin-Dependent Diabetes Mellitus
GERRY H. TAN, M.D., * AND ROGER L. NELSON,
Non-insulin-dependent diabetes mellitus (NIDDM) is
a major health concern for clinicians who are respon-
sible for the care of an aging population. The relation-
ship between hyperglycemia and the chronic compli-
cations of retinopathy, nephropathy, and neuropathy
has been established in patients with insulin-depen-
dent diabetes mellitus, and it is extremely likely that
such a relationship exists in patients with NIDDM as
well. Diet and exercise are the cornerstone for the
management of NIDDM. The assessment of glycemic
control should determine which patients with NIDDM
need more aggressive intervention to control hyper-
glycemia. Pharmacologic treatment options include
oral administration of the sulfonylureas, a biguanide,
and an a-glucosidase inhibitor and subcutaneous ad-
ministration of insulin. Extensive education about
Non-insulin-dependent diabetes mellitus (NIDDM) ac-
counts for 90% of all cases of diabetes diagnosed in the
United States. The increasing prevalence of obesity, an
aging population, and decreased physical activity have led to
the increase in the number of patients diagnosed with this
condition. In the United States alone, the estimated financial
cost of treating NIDDM probably exceeds $30 billion.' The
common misconception that NIDDM is "mild diabetes" has
led to less aggressive intervention. The major aim of medi-
cal practitioners in managing diabetes should be to prevent
the onset or the progression of both macrovascular and mi-
crovascular complications. The recent Diabetes Control and
Complications Trial of patients with insulin-dependent dia-
betes mellitus convincingly demonstrated that intensive
management of hyperglycemia can decrease these complica-
tions.' The pathologic similarity between microvascular
complications in insulin-dependent diabetes mellitus and
NIDDM suggests that the decreased risk of microvascular
From the Division of Endocrinology{Metabolism and Internal Medicine,
Mayo Clinic Rochester, Rochester, Minnesota.
*Current address: Chong Hua Hospital, Cebu, Philippines.
Address reprint requests to Dr. R. L. Nelson, Division of Endocrinology/
Metabolism, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN
55905.
Mayo Clin Proc 1996; 71:763-768
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
M.D.
diabetes and self-monitoring of blood glucose levels
are important components in maximizing glycemic
control. Additional pharmacologic treatment options
are necessary when adequate individualized treat-
ment goals are not attained. The goal of therapy is to
prevent the onset or progression of long-term micro-
vascular and macrovascular complications. In this
review, we present the therapeutic options and outline
our approach to the pharmacologic treatment of
NIDDM. Relevant medical literature on each treat-
ment modality is reviewed, and the cost of therapy
with use of each medication is provided.
(Mayo Clin Proc 1996; 71:763-768)
NIDDM = non-insulin-dependent diabetes mellitus
complications associated with good glycemic control, as
shown in that recent study,' should apply to patients with
NIDDM. This assumption was recently supported by a
randomized, prospective study of Japanese patients with
NIDDM who were followed up for 6 years while they were
receiving an intensive insulin regimen.' In this group of
patients, good glycemic control delayed the onset and de-
creased the progression of nephropathy, retinopathy, and
neuropathy. Several risk factors of macrovascular disease
(lipid profile and platelet adhesiveness) have also been
shown to decrease with good glycemic control.' Therefore,
the purpose of this review is to outline a therapeutic ap-
proach to help patients with NIDDM achieve better glycemic
control (Fig. 1).
NIDDM is considered a heterogeneous disorder, charac-
terized by the overproduction and underutilization of glu-
cose due to the impairment of both insulin secretion and
insulin action.' Diet and exercise remain the cornerstone of
the management of NIDDM, with the aim of maintaining
ideal body weight and reversing potentially damaging meta-
bolic consequences of the disease." When these measures
fail, pharmacologic therapy is indicated.' The current treat-
ment options available for NIDDM include the sulfonyl-
ureas, a biguanide, an a-glucosidase inhibitor (Table 1), and
763 © 1996 Mayo Foundation/or Medical Education and Research
764 TREATMENT OF NIDDM Mayo Clio Proc, August 1996, Vol 71

...
<250 mg/dL

~
Diet and exercise
for 6 weeks
I

t
Normal
t
Abnormal------J.~ Insulin + diet
J and exercise
~ ~
Obese Nonobese

t t
Consider
mettrmin t
Sulfonylurea

Glycemic control not achieved

~
Consider combination therapy or insulin

Fig. I. Algorithm for treating patients with non-insulin-dependent diabetes mellitus. FPG =fasting plasma glucose;
GHgb = glycosylated hemoglobin; LFf = liver function test.

insulin, either alone or in combination with these orally
administered agents. This review deals with our approach in
the use of these drugs.
PHARMACOLOGIC TREATMENT
Sulfonylureas.-The sulfonylureas have been used since
1955. Their mechanism of action is complex, but they
mainly act by stimulating insulin secretion.s Extrapancreatic
effects of these drugs include their ability to increase the
number of insulin receptors and insulin sensitivity." In our
practice setting, the most commonly used sulfonylureas
are glipizide (Glucotrol) and glyburide (Micronase and
DiaBeta). These second-generation sulfonylureas are well
tolerated and have generally supplanted the first-generation
agents; however, no consistent evidence shows that diabetic
control is better with use of these second-generation
sulfonylureas. The duration of action of glipizide and
glyburide is 16 to 24 hours and 18 to 24 hours, respectively,"
A long-acting preparation for glipizide (Glucotrol XL) and a
more potent variant of glyburide (Glynase) are available. A
third sulfonylurea, glimepride (Amaryl), has recently be-
come available. Patients with liver and renal dysfunction have
an increased risk of hypoglycemia, especially when their ca-
pacity to counterregulate is impaired. Although we usually
have no preference regarding the choice of agents, distinct
differences exist between the two drugs. Glyburide has a
longer half-life and can be taken with meals, whereas glipizide
(excluding Glucotrol XL) has a shorter half-life and ideally
should be taken 30 minutes before meals. Unlike glyburide,
glipizide is metabolized to inactive components and is there-
fore preferable for patients with mild renal impairment.
Obtaining detailed information about the other medications
that the patient is taking is extremely important. Drug interac-
tions with trimethoprim, cimetidine , alcohol, and anticoagu-
lants may increase the risk of hypoglycemia, especially with
first-generation agents. Sulfonylurea drugs are a major cause
of drug-induced hypoglycemia. For mild reactions, adjusting
the dose is the only strategy that is necessary. Severe hypo-
glycemic reactions necessitating hospitalization should be
managed by immediate administration of a bolus of 50%
glucose, followed by continuous infusion of 10% or 20%
dextrose. Hypoglycemia can be avoided by teaching patients

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Mayo Clio Proc, August 1996, Vol 71 TREATMENT OF NIDDM 765

Table I.-Oral Therapy for Non-Insulin-DependentDiabetes Mellitus

Doseper day Sideeffects

Drug (mg) Common Rare
Sulfonylureas Hypoglycemia Gastrointestinal,
Glipizide (Glucotrol) 2.5-40 skin rash, liver
Glipizide XL (Glucotrol XL) 5-20 abnormalities
Glyburide (Micronase, DiaBeta) 1.25-20
Glyburide (micronized) (Glynase) 1.5-12
Glimepride (Amaryl) 1-8
Biguanide Anorexia, nausea, Lacticacidosis,
Metformin (Glucophage) 500-2,500 abdominal discomfort, pernicious anemia
diarrhea
a-Glucosidase inhibitor Flatulence, diarrhea,
Acarbose (Precose) 75-300 abdominal cramps

to monitor their blood glucose levels periodically, as subse-
quently outlined. Elderly patients are especially prone to
hypoglycemia.'? Adverse effects such as skin rash or gas-
trointestinal discomfort are minimal. Although the Univer-
sity Group Diabetes Program study suggested increased
mortality from cardiovascular disease," subsequent studies
have failed to confirm this association."
Once the decision has been made to initiate pharma-
cologic treatment, we usually begin with the lowest dose
(glyburide, 1.25 mg; glipizide, 2.5 mg) and gradually titrate
the dose upward by the same increment and no more often
than weekly. Patients are instructed to check their blood
glucose levels before breakfast and supper until stable
glycemic control is reached, at which time, monitoring twice
a week before those two meals is sufficient. We instruct
patients to aim for a preprandial goal range of blood glucose
between 80 and 120 mg/dL or 100 and 140 mg/dL depending
on certain factors (Table 2) and a glycosylated hemoglobin
value of less than 8% or less than 9% (normal, 4 to 7%), in
accordance with the recommendations of the American
Diabetes Association (hemoglobin Ale normal, 4 to 6%).7
Twice-a-day dosing with the sulfonylureas is generally used
when the dose exceeds 10 mg with glyburide or 20 mg with
glipizide. Because studies of the sulfonylureas have shown
that the relationship between the drug dose and its biologic
effect is not linear, further titration of the dose is by incre-
ments higher than these doses. Nevertheless, the greatest
effects on glucose control are achieved with a dosage up to
10 mg daily with both glyburide and glipizide."
Biguanide.-Although metforrnin (Glucophage) has
been used extensively in other parts of the world, it was only
recently approved by the Food and Drug Administration for
the treatment of NIDDM in the United States. In comparison
with the sulfonylureas, this class of drug does not cause
hypoglycemia or weight gain. The exact mechanism of
action is not entirely known. Investigators have shown that
it decreases intestinal absorption of glucose, decreases he-
patic production of glucose, and increases glucose uptake by
peripheral tissues. 14
Investigators estimate that up to 30% of patients will
complain of gastrointestinal adverse effects including
anorexia, nausea, diarrhea, and abdominal discomfort. IS
Malabsorption of vitamin B t 2 occurs in about 30% of pa-
tients, but pernicious anemia is rare. 16 The most serious
adverse effect is lactic acidosis, but the incidence is low and
is estimated to be between 0.01 and 0.067 cases per 1,000
patient-years.'? Lactic acidosis is rare if the drug is used
appropriately-that is, not in patients who have renal impair-
ment (creatinine level, greater than 1.5 mg/dL) or liver dys-
function.
We use metformin as monotherapy for selected patients,
especially obese patients. In the recent United Kingdom
Prospective Diabetes Study, metformin was used in obese
patients and was shown to be as effective as glyburide and
insulin in achieving glycemic control with no change in
mean body weight. 18 Metformin also significantly decreased
mean fasting plasma insulin concentrations." It should be
considered when a second drug is needed for patients who
are responding poorly to maximal doses of sulfonylureas
(glipizide, 40 mg; glyburide, 20 mg) and who are hesitant to
initiate insulin therapy. We usually begin with a low dosage
Table2.-Preprandial Goal Ranges for Patients
With Non-Insulin-DependentDiabetes Mellitus
Bloodglucose level 80 to 120mg/dL and
glycosylated hemoglobin <8%
1. Young age
2. Hypoglycemia awareness
3. No comorbid factors
Bloodglucose level 100to 140mg/dL and
glycosylated hemoglobin <9%
1. Advancing age
2. Hypoglycemia unawareness
3. Comorbid factors

For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
766 TREATMENT OF NIDDM
of 500 mg once daily to avoid gastrointestinal adverse ef-
fects. The dose is increased at weekly intervals until
glycemic control is achieved. A maximal dose of 2.5 g
administered in divided doses can be tolerated by most pa-
tients. The frequency of home blood glucose monitoring is
similar to that outlined for the sulfonlyureas-that is, before
breakfast and supper two times a week.
a-Glucosidase Inhibitor.-Acarbose (Precose) was re-
cently approved by the Food and Drug Administration for
the treatment of hyperglycemia in patients with NIDDM. It
is an intestinal a-glucosidase inhibitor that has been shown
to decrease postprandial hyperglycemia by inhibiting carbo-
hydrate digestion and absorption. 19 In a recent multicenter
trial, acarbose was shown to improve glycemic control in
patients with NIDDM by causing a significant decrease in
mean postprandial glucose levels with a further decrease in
hemoglobin A!e levels of 0.4% in the insulin-treated group
and 0.9% in the diet-treated group in comparison with pla-
cebo." The recommended dosage is 50 mg three times daily
to be taken at the beginning of each meal; if the response is
inadequate after 6 weeks, the dose is titrated up to 100 mg
three times a day. No hematologic or other systemic toxic
adverse effects occurred with dosages as high as 200 mg
three times daily." The only major adverse events noted
were gastrointestinal symptoms including flatulence, diar-
rhea, and abdominal cramps. Such symptoms tend to dimin-
ish with time and be minimized if therapy is initiated with a
low dose. Our experience with this drug is limited. It may
have a role as a second drug for patients in whom sulfonyl-
ureas or metformin fail or as primary therapy for obese
patients with reasonable preprandial glucose levels but dis-
proportionately increased glycosylated hemoglobin values.
Insulin.-Patients with newly diagnosed NIDDM who
have severe hyperglycemia (glucose, greater than 350 mg/
dL) suggestive of substantial insulin deficiency may not
achieve good glycemic control with the orally administered
agents. To prevent further effects of glucose toxicity, we
usually initiate insulin therapy to control blood glucose lev-
els as quickly as possible. Once glycemic control is
achieved in some patients with low insulin requirements-
that is, less than 20 U/day-sulfonylurea therapy may be
initiated, and use of insulin therapy may be discontinued;
blood glucose levels should be closely monitored.
Insulin therapy is also indicated for patients in whom the
sulfonylurea drugs have failed and who are unable to tolerate
the addition of metformin or for those with either significant
renal (creatinine level, greater than 2.0 mg/dL) or liver dys-
function. For our patients with NIDDM, we generally ini-
tiate intermediate-acting human insulin as a single dose. In
our experience, some patients achieve good glycemic control
with this approach. This strategy makes the regimen less
complicated and more acceptable. We provide extensive
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Mayo Clio Proc, August 1996, Vol 71
education to these patients relative to the frequency of blood
glucose testing and insulin dose adjustments, which are usu-
ally titrated up by 10% every 3 days. We prefer to initiate
insulin treatment in the morning. Certainly more complex
regimens can be used (see subsequent discussion) if single
injection therapy is inadequate.
Once the patient's daily insulin requirements reach 60 to
80 U, the total dose of insulin is divided; two-thirds of the
dose is given in the morning, and a third of the dose is given
before the evening meal. We usually suggest that patients
adjust their insulin doses in a "staggered" manner. Instruc-
tions are given to adjust the morning insulin dose first to
achieve a presupper blood glucose level within the goal
range. Once this occurs, the afternoon insulin dose is ad-
justed to achieve a fasting blood glucose within the goal
range. If the glycosylated hemoglobin value is not within the
acceptable goal range (less than 8%, or less than 9% in some
circumstances, see Table 2), patients may need to add short-
acting insulin to the regimen. The need for regular insulin is
based on the determination of blood glucose levels before
lunch and at bedtime. Premixed insulin (NPH [isophane
insulin suspension] and regular insulin) is used only occa-
sionally; dose titration with regular insulin is not possible.
Occasionally, for motivated patients, the multiple daily insu-
lin regimen is initiated at our specialized Diabetes Unit."
This program consists of three injections of regular insulin
given before each meal, with an injection of Ultralente (ex-
tended insulin zinc suspension) before the evening meal. We
rarely recommend insulin pump therapy for these patients.
Combination Oral Medication and Insulin Therapy.-
Although many centers have advocated the combined use of
insulin and a sulfonylurea," this regimen has not been used
routinely at our institution. It is more expensive and com-
plex than treatment with insulin alone, and studies have not
consistently shown it to be more efficacious than optimized
insulin therapy." The concern that hyperinsulinemia associ-
ated with insulin treatment will accelerate atherosclerosis
remains controversial.i-" We occasionally use the combined
regimen for patients whose NIDDM is not controlled with
more than 100 U of insulin. We combine the maximal dose
of glyburide, 10 mg twice daily, or glipizide, 20 mg twice
daily, with insulin and discontinue use of the sulfonylurea
after 1 month if no substantial effect is noted. Limited
studies have indicated a beneficial effect with metformin in
addition to insulin therapy for obese patients with diabetes."
Goals of Therapy and Frequency of Monitoring.-The
preprandial target blood glucose goal range (Table 2) is
between 80 and 120 mg/dL for otherwise healthy, relatively
young patients with NIDDM. For elderly patients and those
with serious medical conditions (for example, coronary ar-
tery disease), a blood glucose goal range between 100 and
140 mg/dL is used. The goals for glycosylated hemoglobin
Mayo ClioProc,August 1996, Vol71 TREATMENT OF NIDDM 767

Table 3.-Patient's Cost per Dose or per Day for daily expenses total about $35 a week with the combination
Treatment of Non-Insulin-Dependent Diabetes Mellitus therapy (glyburide, 10 mg twice daily, and metformin, 2.5 g
Dose Cost daily) in comparison with a total of about $7 a week with 40
Medication (mg) per dose U of intermediate-acting insulin alone. The cost for home
glucose monitoring is generally $0.70 per test; thus, testing
Sulfonylureas
Glyburide twice a day two times a week would cost approximately $3
Micronase 2.5 $ 0.37 per week.
5 0.60
DiaBeta 2.5 0.36 CONCLUSION
10 0.65 The management of NIDDM is challenging to both the pa-
Generic 2.5 0.34
5 0.53 tient and the physician. Of importance, each person with
Glynase 3 0.55 diabetes must be aware of the known relationship between
6 0.97 hyperglycemia and chronic complications of the disease.
Glipizide Most patients tend to neglect to follow instructions on home
Glucotrol 5 0.39 glucose monitoring partly because they have not been taught
10 0.65
Generic 5 0.35 how to adjust the dose of oral medication or insulin based on
10 0.58 their glucose readings. Monitoring of glycemic status
Glucotrol XL 5 0.31 should be a cornerstone of diabetes management. 26
10 0.67 Herein we outlined our approach to the treatment of
Glimepride hyperglycemia in patients with NIDDM. Newer, probably
Amaryl 2 0.45
4 0.80 more efficacious agents are now in various stages of pharma-
Biguanide ceutical development. 19 Whatever approach is used, each
Metformin physician's goal should be to prevent long-term complica-
Glucophage 500 0.48 tions associated with hyperglycemia.
850 0.87
a-Glucosidase inhibitor
Acarbose REFERENCES
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Questions About Treatment of Non-Insulin-Dependent Diabetes Mellitus

(See article, pages 763 to 768)

1. Which one of the following is a benefit of the second- 4. Which one of the following statements most accurately
generation su1fonylureas in comparison with the older describes the relative cost differential between
su1fonylureas? maximal combined doses of a sulfonylurea and a
a. Less expense biguanide versus 40 U of NPH (isophane insulin
b. Minimal if any drug-drug interaction suspension)?
c. Improved diabetic control a. Combined therapy is 5 times more expensive
d. Less potent b. Combined therapy is similar to the cost of insulin
e. Less hypoglycemia therapy
c. Insulin is twice as expensive
2. Which one of the following is true regarding biguanides
d. Insulin is 5 times as expensive
relative to sulfonylureas? e. Combined therapy is 3 times as expensive
a. No hypoglycemia
b. Weight gain 5. Which one range of the following preprandial glucose
c. Safe for patients with renal insufficiency levels is an appropriate goal for the stated age in an
d. No gastrointestinal side effects otherwise healthy person with non-insulin-dependent
e. Stimulated insulin secretion diabetes mellitus?
a. 80 to 100 mg/dl., age 65 years
3. Which one of the following side effects can be
b. 100 to 140 mg/dL, age 65 years
commonly encountered in patients taking either
c. 80 to 140 mg/dL, age 90 years
acarbose or metforrnin? d. 120 to 160 mg/dL, age 48 years
a. Gastrointestinal e. 80 to 100 mg/dL, age 45 years
b. Rash
c. Hypoglycemia
d. Impaired liver function Correct answers:
e. Hyponatremia 1. b, 2. a, 3. a, 4. a, 5. b

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