| Class | Drug | Potential side effects | Contraindications | Comments | Relative cost* |
|---|---|---|---|---|---|
| Alpha glucosidase inhibitors | Acarbose (Precose) Miglitol (Glyset) | Flatulence; abdominal pain; diarrhea | — | To reverse hypoglycemia (usually only in setting of combination therapy), treat with oral glucose, not sucrose | $$ |
| Amylin analogues | Pramlintide (Symlin) | Nausea and vomiting; anorexia; headache | Gastroparesis; lack of awareness of hypoglycemia; A1C > 9 percent | Severe hypoglycemia can occur, especially with coadministration of insulin; injectable medication; reduce insulin dose by 50 percent when initiating therapy | $$ |
| Biguanides | Metformin (Glucophage) | Nausea; diarrhea; flatulence | Renal insufficiency (discontinue if creatinine level ≥ 1.4 in women or ≥ 1.5 in men); conditions that predispose to acidosis (e.g., liver disease, hypoxemia, sepsis); discontinue during acute illness and before radiographic procedures requiring intravenous dye (may restart 48 hours after procedure if serum creatinine levels are unchanged) | Decreases circulating androgen levels and increases rates of ovulation in women with polycystic ovarian syndrome; modest weight loss may occur; pregnancy category B based on animal studies but not well-studied in pregnant women | $† |
| Incretin enhancers | Saxagliptin (Onglyza)‡ Sitagliptin (Januvia) | Nausea and vomiting | Adjust dosage in patients with renal impairment | — | NA |
| Incretin mimetics | Exenatide (Byetta) | Nausea and vomiting; diarrhea; dizziness | Not recommended in patients with severe renal disease (creatinine clearance < 30 mL per minute) | Injectable medication; modest weight loss may occur | $$$$ |
| Insulin secretagogues: sulfonylureas | Chlorpropamide (Diabinese)§ | Hypoglycemia; weight gain Glimepiride (Amaryl) Glipizide (Glucotrol) Glyburide (Micronase) Tolazamide (Tolinase)§ Tolbutamide (Orinase)§ | — | — | $† |
| Insulin secretagogues: nonsulfonylureas | Nateglinide (Starlix) | Hypoglycemia Repaglinide (Prandin) | — | Metabolized through CYP3A4 | $$$ |
| Thiazolidinediones | Pioglitazone (Actos) Rosiglitazone (Avandia) | Weight gain; fluid retention | Hepatic disease; alanine transaminase level > 2.5 times normal; pregnancy; congestive heart failure (New York Heart Association class III or IV); use with caution in patients with edema | Association between rosiglitazone and cardiovascular events12,13 | $$$$ |