Two aspects of this study stand out. First, the A1c at which a second agent is added is 8.4%, and it takes about three and a half years until that second agent is added. It is unlikely that patients are in good control during that three-and-a-half-year period, and far more likely that therapeutic inertia, due to the reticence of both clinicians and patients to add additional medications, leaves patients exposed to unnecessarily high levels of blood glucose for prolonged periods of time. This is a reminder to regularly assess whether patients are meeting their A1c targets, and if they are not, to escalate therapy. The second aspect of note, is that even with the new diabetes medications available, sulfonylureas still account for almost half of all second-line oral therapies, despite the fact that they have a high incidence of hypoglycemia, lead to weight gain, and have limited durability of action. Many of the newer medications have a lower incidence of hypoglycemia, longer durability of action, and lead to weight loss instead of weight gain. There may be times when sulfonylureas are a good choice and, while they are less expensive than newer agents, but the degree of use of sulfonylureas as second line agents should prompt us to approach the decision of which medicine to use after metformin thoughtfully, now that there are many excellent medications from which to choose.¹ —Neil Skolnik, MD

1. Skolnik NS, Jaffa F, Kiriakov Y. Individualizing dual therapy for type 2 diabetes mellitus. J Fam Pract. 2017;66(4):300-308.