4. Duplicative Therapy

Administering two or more oral sulfonylureas concurrently is not justified. The concomitant use of two or more oral sulfonylureas will be reviewed.

Combined administration of nateglinide or repaglinide and oral sulfonylureas is not justified as both drug classes stimulate insulin secretion. Adjunctive use of meglitinides and oral sulfonylureas will be reviewed.

The risk of hypoglycemia may increase when acarbose or miglitol is added to pre-existing oral hypoglycemic or insulin therapy. Blood glucose levels should be monitored closely when alpha glucosidase inhibitor therapy is initiated in patients already receiving oral hypoglycemic or insulin therapy.

Adjunctive administration of rosiglitazone and insulin is not recommended as a greater incidence of myocardial ischemic events was observed in clinical trials when rosiglitazone was added to insulin therapy.

Concurrent administration of thiazolidinediones or metformin with sulfonylureas may result in an increased frequency of hypoglycemic episodes. Blood glucose levels should be closely monitored if patients are prescribed thiazolidinediones or metformin and oral sulfonylureas concomitantly, and oral sulfonylurea dosage reductions should be considered.

Concurrent administration DDP-4 inhibitors and sulfonylureas, with or without metformin, have resulted in significant reductions in HbA1c and fasting plasma glucose compared to placebo. The risk of hypoglycemia with DDP-4 inhibitors in combination with metformin and TZDs is comparable to that observed with placebo; however, the incidence of hypoglycemia in patients prescribed DDP-4 inhibitors concurrently with sulfonylureas is greater than that seen with placebo. The incidence of hypoglycemia in patients prescribed DDP-4 inhibitors and insulin concurrently has not been adequately evaluated. Therefore, blood glucose levels should be closely monitored if patients are prescribed DDP-4 inhibitors and oral sulfonylureas or insulin concomitantly, and oral sulfonylurea dosage reductions should be considered.

Concomitant use of multiple SGLT2 inhibitors is not recommended due to similar pharmacologic mechanisms and increased risk of adverse events. Combined administration is not advised and will be reviewed.

The concurrent use of oral semaglutide when combined with an insulin secretagogue, such as a sulfonylurea, or insulin may increase the risk of hypoglycemia, including severe hypoglycemia. The risk of hypoglycemia may be reduced by decreasing the dose of the insulin secretagogue or insulin.