Selecting the Optimal First-Line Drug for Type 2 Diabetic Patients.

[Argirios Argiriou]

May 17, 2016

Selecting the Optimal First-Line Drug for Type 2 Diabetic Patients

Jamaluddin Moloo, MD, MPH reviewing Maruthur NM et al. Ann Intern Med 2016 Apr 19.

Metformin continues to be the best choice for most patients.

Options for treating patients with type 2 diabetes continue to grow. In this systematic review and meta-analysis of 204 studies, researchers evaluated the comparative effectiveness and safety of available agents.

Eighty-one percent of included studies were randomized controlled trials (RCTs). Moderate-strength evidence showed that metformin monotherapy was associated with lower long-term (≥2 years) cardiovascular-related mortality than was sulfonylurea monotherapy (relative risk, 0.65 in RCTs), whereas evidence was insufficient or of low strength for defining differences in all-cause mortality and macrovascular or microvascular outcomes. In the short term, most medications lowered glycosylated hemoglobin levels by similar amounts; however, dipeptidyl peptidase-4 (DPP-4) inhibitors were less effective than was metformin or a sulfonylurea. Similarly, most metformin-based combination therapies lowered glucose by similar amounts, except for the combination of metformin plus DPP-4 inhibitors, which was inferior to metformin plus glucagon-like peptide-1 (GLP-1)–receptor agonists. Weight remained stable or decreased with metformin, DPP-4 inhibitors, GLP-1–receptor agonists, and sodium-glucose cotransporter-2 (SGLT-2) inhibitors; weight increased with sulfonylureas, thiazolidinediones, and insulin. Sulfonylureas conferred the highest risk for hypoglycemia, and SGLT-2 inhibitors conferred the highest risk for vaginal fungal infections. The researchers did not find excess risk for lactic acidosis with metformin.

COMMENT

The findings of this meta-analysis support current guidelines, which recommend using metformin as a first-line agent to treat adults with type 2 diabetes. Note that the FDA is modifying its restrictions on metformin use with renal impairment: According to new labeling, metformin is contraindicated only when glomerular filtration rate (GFR) is <30 mL/minute/1.73 m2, and it can be used with caution in patients with GFRs of 30 to 45 mL/minute/1.73 m2.

EDITOR DISCLOSURES AT TIME OF PUBLICATION

Disclosures for Jamaluddin Moloo, MD, MPH at time of publication
Grant / Research supportColorado Health Foundation

CITATION(S):

Maruthur NM et al. Diabetes medications as monotherapy or metformin-based combination therapy for type 2 diabetes: A systematic review and meta-analysis. Ann Intern Med 2016 Apr 19; [e-pub]. (Δεν είναι ορατοί οι σύνδεσμοι (links). Εγγραφή ή Είσοδος)

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