Many type 2 diabetes (t2dm) patients are unable to achieve or maintain their A1c goals even when appropriately treated with oral agents. Currently, the combination of metformin with a sulfonylurea (MET/SFU) is a very commonplace initial combination. Because T2DM is a progressive disorder, and because some agents lose efficacy over time, most patients must recognize that augmentation of treatment is usually required. But which next step is best when MET/SFU is insufficient?

Canaglifozin (CAN) is the first approved member of a new class of agents for T2DM, known as the SGLT2 inhibitors, which work by blocking renal reabsorption of excess glucose, leading to increased urinary glucose excretion. Sitagliptin (SIT) is one of three approved DPP-4 inhibitors that work by increasing blocking glucagon and stimulating insulin production when glucose is elevated.

In a 1-year trial comparing the addition of CAN or SIT to MET/SUF (n = 755), A1c reduction with CAN was substantially greater (-1.03 vs -0.66) and both agents were well tolerated. SGLT2 inhibitors are potentially useful when A1c goals are not attained or maintained with MET/SUF.