Repositioning Tradition: A Narrative Review and Expert Opinion on the Clinical Positioning of Glimepiride and Metformin in Nepal's Type 2 Diabetes Mellitus (T2DM) Landscape

The prevalence of type 2 diabetes mellitus (T2DM) is rising in Nepal, making the glimepiride-metformin fixed-dose combination (FDC) a commonly used treatment due to its complementary mechanisms of action, effectiveness, and cost-efficiency. This expert opinion aims to identify diverse patient populations most likely to benefit from this combination and guide evidence-based, individualized diabetes management in Nepal. An expert advisory panel consisting of nine clinicians from Nepal convened across two meetings (held in February and March 2025) to share their perspectives on the glimepiride and metformin FDC. Their insights were based on real-world practice patterns, treatment challenges, and local prescribing dynamics to develop clinically relevant recommendations. The expert panel discussions, supported by clinical data, demonstrated that the glimepiride-metformin FDC is a widely used, effective, and affordable option for managing T2DM. It is particularly beneficial for patients requiring rapid glycemic control, those recently diagnosed, and individuals in resource-limited settings. The FDC was found to provide significant glycated hemoglobin (HbA1c) reductions, tolerability at low doses, and improved treatment adherence due to its simplified regimen. While challenges such as the risk of hypoglycemia, weight gain, and limited formulation availability persist, the combination remains a preferred choice in settings where cost and availability are critical concerns. The panel emphasized the importance of individualized dose titration and regular follow-up to optimize outcomes. The glimepiride and metformin FDC continue to be a clinically effective, affordable, and widely applicable treatment option for T2DM in Nepal, particularly suited to meet the needs of diverse patient populations, specifically in resource-limited settings.