Table 2.

Recommendations from regional or national guidelines.^3,16-25

Sl. no.	Region	Guidelines on the use of SUs
1	Canada, 201916	• Use SUs with caution among the elderly due to the increased risk of hypoglycemia. • Start with half the dose in elderly and up-titrate gradually. • Prefer gliclazide, gliclazide MR, or glimepiride as the risk of hypoglycemia is lesser.
2	Columbia, 201617	• People with recently diagnosed T2DM and HbA1c >9% who are intolerant to the combination of metformin and DPP4 or SGLT2 inhibitors are recommended a combination of metformin with a newer SU (glimepiride or gliclazide). • People receiving SUs are recommended to implement glucose self-monitoring to detect and treat any episodes of hypoglycemia appropriately. • All SUs (except glipizide) are contraindicated if the glomerular filtration rate is >30 mL/min.
3	Australia, 201818	• Recommends SUs as second-line therapy following metformin or as an add-on along with metformin or insulin. • Individuals on SUs should be encouraged to self-monitor their glucose levels.
4	Nigeria, 202019	• Recommends modern SUs especially in individuals aged >40 years old, who have had DM for <10 years.
5	Uganda, 201620	• Add-on therapy with glibenclamide or glimepiride is recommended if the glycemic targets are not achieved with both lifestyle therapy and metformin.
6	The Middle East and North Africa, 201921	• Recommends SUs as fixed-dose combinations along with two or three OADs.
7	China 22	• Xiao Ke Wan, a fixed-dose combination of SU (glyburide) and certain traditional Chinese medications are recommended, as risk of hypoglycemia is lower compared to glyburide alone.
8	Korea, 201923	• Recommends SUs in individuals who are intolerant to metformin.
9	Singapore, 201424	• Recommends SUs as a reasonable alternative to metformin in first-line pharmacotherapy. • Recommends self-monitoring of blood glucose in individuals using SUs.
10	India, 202025	• SUs as second-line agents to be used in persons with T2DM who are not obese. • Risk of hypoglycemia is lower with SUs (especially gliclazide MR) in South Asians and are hence preferred in this population. • The dose of SUs should be reduced when prandial insulin is introduced. • Glimepiride and gliclazide MR, are recommended in persons at increased risk of or with CVD. • Second-generation SUs are recommended in the treatment of diabetic kidney disease. • Self-monitoring of blood glucose (4 times/day) is recommended in individuals with new-onset/uncontrolled/acute illness receiving SUs and should include prandial and bedtime values.
11	Austria, 20203	• SUs are preferred after SGLT-2 inhibitors, GLP-1RAs, pioglitazone, and DPP-4 inhibitors.
12	Belgium, 20203	• SUs are used as a second-line therapy.
13	Canada, 20203	• SUs are considered second-line therapy.
14	Germany, 20203	• SUs are a second-line therapy option.
15	Greece, 20203	• Second-line therapy with SUs or pioglitazone if cost is an issue.
16	Hungary, 2020†3	• SUs to be considered as first-line therapy if metformin is intolerable or contraindicated. • GPs widely use SUs (mainly gliclazide) as they can prescribe only metformin and SUs as initial therapy; although SUs are not the preferred as an add-on therapy. • Age, body weight, co-morbidities, hypoglycemia risk, cost and preference should be considered before initiating an add-on medication.
17	Israel, 2020‡3	• SUs preferred as fourth-line therapy if cost is a concern.
18	Italy, 20203	• Gliclazide can be preferred, if an SU is necessary; glibenclamide is contraindicated.
19	The Netherlands, 20203	• SUs (gliclazide) is preferred only as a second-line add-on therapy.
20	Poland, 20203	• Individualize the choice of further drugs considering the side-effects, effectiveness, risk of hypoglycemia and weight gain, cost, and patient preferences.
21	Portugal, 20203	• The choice is individualized according to HbA1c levels (efficacy), side effects, weight, hypoglycemia risk, age, health status, life expectancy, patient preferences, and cost.
22	Romania, 2020‡3	• First-line monotherapy with metformin or SUs (if metformin is not tolerated) or insulin (if required). • Metformin or SU along with all other classes of drugs (SGLT2 inhibitors, DPP4 inhibitors, GLP-1RAs, pioglitazone, insulin, acarbose, or repaglinide), or basal insulin (initial diagnosis) along with all other classes are preferred triple/quadruple drug combinations for second-line therapy.

CVD, cardiovascular disease; DPP4, dipeptidyl peptidase 4; HbA_1C, glycated hemoglobin; MR, modified release; SGLT2, sodium–glucose co-transporter-2; SU, sulfonylureas; T2DM, type 2 diabetes mellitus. ^†The guideline was published in January 2017 and will expire on 31 December 2019; current work is underway on the updated version, which will be available from 1 January 2020. CV events and risks will be considered as important factors; SGLT2-is and GLP1-RAs will be preferred in patients with CV events and/or risks; ^‡Guidelines currently being revised.