Multiple OHAs... OK or not?

..If glucose levels are not adequately controlled with metformin and sulfonylurea and the decision is made to hold off on insulin injections and continue with oral medications, then the recommendation is to choose either a thiazolidinedione (rosiglitazone [Avandia®] or pioglitazone [Actos®]), a glucagon-like peptide 1 [GLP-1] agonist such as Byetta), or Januvia® (sitagliptin), an oral medication that blocks the breakdown of GLP-1. Actos is associated with an improved lipid profile and a probable decrease in heart attacks; some studies found that Avandia increased the likelihood of heart attacks.

Avandia and Actos are expensive and both can cause fluid retention, heart failure, weight gain, and bone fractures. Byetta produces weight loss but requires two injections daily, is expensive, and frequently causes gastrointestinal side effects. The long-term safety of Byetta and Januvia is not established.
When they discuss treatment choices with their physician, people with type 2 diabetes should be aware of these recommended priorities for treatment, as well as of the positive and negative features of each therapeutic option. It is an unfortunate fact that type 2 diabetes worsens over time, so that insulin or multiple oral medications are needed to control blood glucose well enough to diminish the chances of long-term complications.