In a 65-year-old man with Type 2 diabetes, which pharmacological management is most appropriate after dietary changes fail?

The most appropriate pharmacological management for a 65-year-old man with Type 2 diabetes, particularly after dietary changes have not achieved adequate glycemic control, is a biguanide, specifically metformin. Metformin is typically the first-line medication in the management of Type 2 diabetes due to its proven efficacy in lowering blood sugar levels, its safety profile, and its ability to promote weight loss rather than weight gain.

Biguanides work by decreasing hepatic glucose production and increasing insulin sensitivity in peripheral tissues. This dual action helps improve blood glucose control effectively without causing significant hypoglycemia, which is an important consideration for older patients who may be more susceptible to the adverse effects of medications. Additionally, metformin has cardiovascular benefits, which is particularly beneficial given that this patient is of older age and likely has comorbid conditions associated with diabetes.

While other medications, such as sulfonylureas and SGLT2 inhibitors, have their own benefits, they are generally considered after metformin, as biguanides provide an essential foundation for diabetes management. Sulfonylureas increase insulin secretion from the pancreas but can lead to weight gain and risk of hypoglycemia, which may be concerns in older adults. SGLT2 inhibitors offer benefits