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There are a range of therapeutic options available for the management of type 2 diabetes in the elderly. Diet remains the mainstay of treatment although this must be realistic. If diet alone is unsuccessful then, for most patients, short-acting sulphonylurea agents are the treatment of choice. Second line agents include the biguanide, metformin, or an alpha-glucosidase inhibitor. A significant proportion of type 2 diabetic patients will, however, eventually require insulin to alleviate symptoms of poor control and improve glycaemia. In this article I discuss the therapeutic options available for diabetic management in the elderly, with particular emphasis on the pros and cons of insulin treatment.