What is recommended if metformin fails or is contraindicated?

• A. Insulin
• B. SGLT inhibitors or GLP-1 receptor agonists
• C. Metformin
• D. Lifestyle modification only

Answer: (B)

When metformin can’t be used or doesn’t achieve target control, the best next-step options are SGLT2 inhibitors or GLP-1 receptor agonists. These classes have strong evidence showing cardiovascular and kidney benefits, and they generally provide good glucose lowering with favorable effects on weight and a low risk of hypoglycemia (especially compared with insulin). This makes them preferred additions for many patients who cannot take metformin or who need more control beyond metformin alone.

Insulin can be used if glycemic control remains above target after trying other agents or in cases of very high blood glucose, but it’s not the primary recommended next step when metformin is contraindicated or has failed. Lifestyle changes by themselves are insufficient for persistent hyperglycemia.