Real World Effectiveness of Rosiglitazone Added to Maximal (Tolerated) Doses of Metformin and a Sulfonylurea Agent

Patients with newly diagnosed type 2 diabetes who have no or only mild symptoms should be started on a regimen of diet and exercise. Unfortunately, as many as 95% of patients do not achieve adequate control after 3 months of nonpharmacologic therapy (1). When medical therapy is initiated, patients are often started on either a low dose of a sulfonylurea agent or metformin. If control is not attained with the maximal dose of one, the second is usually added until adequate control is achieved or a maximal dose is reached. Since glitazones are so expensive, we use them only after maximal (tolerated) doses of metformin and sulfonylurea agents are reached and control remains unsatisfactory. Only a few studies (2–6) have examined the effectiveness of adding a glitazone as the third oral agent. These have used mean A1C levels as the outcome, which does not provide information on the proportion of patients who can be expected to respond. Our algorithm-based approach mandates starting small doses of either a sulfonylurea agent (lean patients) or metformin (obese patients) and titrating the dose upward in a stepwise fashion every 2 weeks until either a fasting plasma glucose (FPG) concentration of ≤130 mg/dl is attained or a maximal (tolerated in the case of metformin) dose is reached. If the …