We were very interested to learn of Dr. De’s (1) experience with triple oral therapy in a population that was comparable to that in our study (2). We observed, in 48 patients, a fall in A1C levels from 9.3 to 7.5% in 4 months, while De saw a decrease from 9.2 to 8.2% in the same time period. Perhaps the difference in the final values was due to the fact that we used a maximal dose of rosiglitazone, whereas he used submaximal doses. Sixty-five percent of our patients reached a goal A1C level of <7.5% at 4 months compared with 41% of his patients; once again, this difference was perhaps due to the differing glitazone doses. Sixty-one percent of our patients, as opposed to all of his, remained at goal at 1 year.

We would disagree with limiting glitazones in patients failing maximal doses of a sulfonylurea and metformin to those with A1C levels of ≤9.0%. Twenty-four of our 48 patients had initial A1C levels >9.0%. Their average initial value of 10.6% fell to 8.0% at 4 months, with 13 achieving the target level of <7.5%. Of these 13, 6 were not taking rosiglitazone at 1 year, 4 because of failure to maintain the target level, 1 because of edema, and 1 due to loss at follow-up. Even though only approximately half of those with A1C levels >9.0% responded, why not give these patients the opportunity to reach the A1C target level with triple oral therapy? Insulin administration requires much more of a lifestyle change for patients (as well as increased demands on conscientious providers). If the A1C target is not achieved (or once reached, not maintained), patients should then have insulin added to their regimen. Treating to target remains the crucial goal.

1
De P: Real world effectiveness of rosiglitazone added to maximal (tolerated) doses of metformin and a sulfonylurea agent (Letter).
Diabetes Care
27
:
3027
,
2004
2
Roy R, Navar M, Palomeno G, Davidson MB: Real world effectiveness of rosiglitazone added to maximal (tolerated) doses of metformin and a sulfonylurea agent: a systematic evaluation of triple oral therapy in a minority population (Brief Report).
Diabetes Care
27
:
1741
–1742,
2004