Yes
Patient needs to start Insulin.
Discuss with patient.
If agrees:
Commence as per insulin initiation pathway
If declines insulin and no contraindications then:
Add Sitagliptin 100mg/day and review in 2 weeks. If target still not met and patient unwilling to have insulin
Add Pioglitazone 30mg od and review at 6 weeks.(consider fracture risk , do not use > 10% www.shef.ac.uk/FRAX/ to caculate)
Rediscuss insulin if targets not achieved/side effects from Glitazone
Acarbose remains an option for triple/quadruple oral therapy if the patient is resistant to going onto insulin but chances of achieving targets would be slim at this stage.
If on oral hypoglycaemic therapy with 3 agents and targets not achieved then proceed to insulin therapy.