Philadelphia—Metformin remains the preferred first agent for lowering blood sugar in patients with type 2 diabetes, but the need for a second drug should be carefully weighed, according to new guidelines endorsed by the American College of Physicians.
The evidence-based clinical practice guideline on oral pharmacologic treatment of type 2 diabetes was published recently in Annals of Internal Medicine.
“Metformin, unless contraindicated, is an effective treatment strategy because it has better effectiveness, is associated with fewer adverse effects, and is cheaper than most other oral medications,” said Nitin S. Damle, MD, MS, MACP, president of the ACP. “The escalating rates of obesity in the U.S. are increasing the incidence and prevalence of diabetes substantially. Metformin has the added benefit of being associated with weight loss.”
If it is determined that a second oral medication should be used to lower high blood sugar, ACP recommends that physicians consider adding either a sulfonylurea, thiazolidinedione, SGLT-2 inhibitor, or DPP-4 inhibitor to metformin. Adding the second medication isn’t automatic, however.
“Adding a second medication to metformin may provide additional benefits,” Damle explained. “However, the increased cost may not always support the added benefit, particularly for the more expensive, newer medications. ACP recommends that clinicians and patients discuss the benefits, adverse effects, and costs of additional medications.”
The update of the ACP’s 2012 guideline on the comparative effectiveness and safety of oral medications for the treatment of type 2 diabetes was prompted by several new studies evaluating diabetes medications, as well as recent FDA approvals of several new medications, according to the authors.
ACP’s guideline is based on a systematic review of randomized controlled trials and observational studies on the comparative effectiveness of oral medications for type 2 diabetes. Evaluated interventions include metformin, thiazolidinediones, sulfonylureas, and dipeptidyl peptidase-4 inhibitors. Evaluated outcomes, meanwhile, included: intermediate outcomes of hemoglobin A1c, weight, systolic blood pressure, and heart rate; all-cause mortality, cardiovascular and cerebrovascular morbidity and mortality; retinopathy, nephropathy, neuropathy; and harms.
New information in the updated review includes evidence on the FDA-approved sodium–glucose cotransporter-2 (SGLT-2) inhibitor class of drugs and on additional dipeptidyl peptidase-4 (DPP-4) inhibitors, as well as further evidence on other drugs included in the 2011 review.
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