Table 3.

Appropriate and optimal use of SUs as recommended by guidelines.

Therapy type	Usage
SU monotherapy	Monotherapy as first line if metformin is not tolerated or contraindicated.3,10,12
SU as second line	When there are no indicators of high-risk or established CKD, ASCVD, or HF, and cost of treatment is a major factor. 5
SU as triple-combination therapy	As third-line therapy with metformin and other agents (DPP4i, insulin, pioglitazone, GLP1-RA). 12
SU as quadruple-combination therapy	In combination with metformin + GLP1RA + DPP4i or metformin + DPP4i + SGLT2i. 3
SUs in combination with insulins	Gliclazide and glimepiride may be used as second line with insulin-based therapies and metformin.3,18
SUs in elderly population	Gliclazide and glimepiride may be used in elderly patients, but with caution.6,37
SUs in Ramadan fasting	Second-generation SUs, such as gliclazide and glimepiride, are recommended, and avoid glibenclamide. Dose reduction may be required.6,36
SUs in CVD or renal impairment	Can be used in patients with CVD. 6 Patients with renal impairment are at risk of developing hypoglycemia following SU therapy; SUs to be used with caution in this group of patients. 6

ASCVD, atherosclerotic cardiovascular disease; CKD, chronic kidney disease; CVD, cardiovascular disease; DPP4i, dipeptidyl peptidase 4 inhibitor; GLP1RA, glucagon-like peptide-1 receptor agonist; HF, heart failure; SGLT2i, sodium–glucose co-transporter-2 inhibitor, SU: sulfonylurea.