Yes
Insulin is likely to be the most effective option for symptoms but may make weight gain a major problem. For those with a BMI>30 maximising tablet options and weight loss is the better option. Discuss the options available:
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Insulin as per insulin initiation pathway
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Addition of Sitagliptin 100mg followed by/or Pioglitazone 30mg od (consider fracture risk , do not use > 10% www.shef.ac.uk/FRAX/ to caculate),if no contraindication
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If BMI > 35 on maximum tablets consider exenatide. (will need specialist referral)
If patient chooses insulin then follow insulin pathway.
If patient chooses Sitagliptin/Pioglitazone then review in 6 weeks and add in Pioglitazone* or increase to 45 mg od if targets not met, if patient unwilling to have insulin.
If on maximum dual/monotherapy therapy but second/third agent contraindicated or patient intolerant then proceed to insulin ( ?Exenatide)
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.