Table 1.

Recommendations from international organizations/associations/societies related to the use of sulfonylureas.^5,10-15

Sl. No	International guidelines	Guideline recommendations for use of SUs
1	ADA 5	• Combination therapy with any of the six preferred medications has been recommended if target HbA1C levels are not attained with metformin monotherapy. • The preferred medications include: SUs, DPP-4 inhibitors, thiazolidinedione, GLP-1 RA, SGLT2 inhibitors, or basal insulin. Patient factors and drug-specific effects are to be considered while deciding the therapy. • SUs are recommended: – as third-line therapy in people with T2DM and ASCVD or CKD, following the failure of SGLT2i or GLP-1RA – in individuals without underlying cardiac or renal problems. – as the second-line therapy option when the cost of treatment is a major factor; if there is no risk or established CKD, ASCVD, or HF.
2	IDF 10	• When metformin is not tolerated, SUs (except glibenclamide/glyburide) can be prescribed. • Metformin can be combined with SUs (except glyburide/glibenclamide), SGLT2 inhibitors or DPP4 inhibitors. • When starting an SU, the patient should be educated about how to prevent, recognize, and treat hypoglycemia.
3	ISPAD 11	• SUs are not approved for use in those <18 years of age. • People on SUs should be encouraged to do self-monitoring of blood glucose to detect asymptomatic hypoglycemia.
4	NICE 12	• SUs are recommended as an initial treatment regimen in individuals who are intolerant to metformin. • The use of insulin or SUs is recommended in people with T2DM who are symptomatically hyperglycemic. • Recommend dual therapy with metformin and SUs in adults with T2DM, whose HbA1c levels remain uncontrolled with initial metformin monotherapy. • SUs are also recommended as third-line therapy as part of a triple-drug regimen along with metformin and DPP-4 inhibitors or with metformin and pioglitazone.
5	WHO 13	• SUs are recommended when glycemic control is not achieved with metformin monotherapy or in those metformin intolerance. • Recommend the usage of modern SUs, such as gliclazide, for better safety.
6	EASD 14	• Addition of SU effectively reduces CV risk compared to lifestyle interventions alone; hence, it is recommended in people with T2DM. • Newer SUs, such as glimepiride, are associated with comparatively lesser adverse events, such as hypoglycemia and cardiovascular toxicity.
7	AACE 15	• SU is recommended as first-line therapy, as an alternative to metformin in select patients. • In addition to metformin, dual or triple therapy using SU is recommended with caution.

AACE, American Association of Clinical Endocrinologists; ADA, American Diabetes Association; ASCVD, atherosclerotic cardiovascular disease; CKD, chronic kidney disease; CVD, cardiovascular disease; DPP4i, dipeptidyl peptidase 4 inhibitor; EASD, European Association for the Study of Diabetes; GLP1RA, glucagon-like peptide-1 receptor agonist; HF, heart failure; IDF, International Diabetes Federation; ISPAD, International Society for Pediatric and Adolescent Diabetes; NICE, National Institute for Health and Care Excellence; SGLT2i, sodium–glucose co-transporter-2 inhibitor; SU, sulfonylurea; WHO: World Health Organization.