OBJECTIVES: To describe the sequential treatment classes of type 2 diabetes (T2DM) patients initiating  antidiabetic drug therapy in the Netherlands, United Kingdom (UK), Spain, Italy and France. To describe treatment scaling (intensification or de-intensification) in the overall T2DM population. METHODS: Antidiabetic drug use during a 5-year study period (2007-2011/2008-2012) (n=639,088) was obtained from electronic healthcare databases. A standardized analytic tool performed treatment pattern analyses in each database for the overall population and those initiating treatment. Oral monotherapy was defined as first line, oral dual therapy as second line, multiple oral treatments or oral in combination with an injectable as third line and injectables only as fourth line therapy. RESULTS: Newly treated patients represented 33-42% of the overall T2DM population. Metformin monotherapy was the most common initial therapy (65%-87%). Around 35% (Netherlands, Italy, UK) to 45% (Spain, France) switched treatment within the study period. The first switch was most often to metformin plus a sulfonylurea (SU) in the Netherlands (47%), UK (45%), Spain (22%), Italy (17%), but to DPP4 inhibitors in France (15%). DPP4 inhibitor use increased during the study period (France 0% to 27%, UK and Spain <1% to 9%) but remained limited in the Netherlands (4%) and Italy (2%). In the total cohort, first line treatment was most prevalent over all the years in all countries (around 50%). Intensification was the most common switch. Switching patients mostly stepped up or down one line at a time, but larger steps were also observed. Fourth line therapy was uncommon in France (1-2%) but accounted for about 10% in the other countries. CONCLUSIONS : SU remained the most common add-on treatment to metformin in most European countries while DPP4 inhibitor use was common in France and increased in other countries. Most T2DM patients are treated with oral monotherapy.