Metformin should be the first drug of choice in oral therapy for type 2 diabetics who don’t respond to diet and lifestyle changes, according to a new guideline.

-Team@CMHF

• A second agent can be added if metformin monotherapy fails to control hyperglycemia, but there’s insufficient evidence to recommend one secondary agent over another, Amir Qaseem, MD, PhD, director of clinical policy at the American College of Physicians, and colleagues wrote in the organization’s new guideline for the management of type 2 diabetes
• We found that most diabetes medications reduced blood sugar levels to a similar degree, Qaseem said in a statement.
• However, metformin is more effective compared to other type 2 diabetes drugs in reducing blood sugar levels when used alone and in combination with other drugs.
• There are currently 11 classes of drugs approved for treating hyperglycemia in type 2 diabetes the researchers wrote, and most patients receive more than one class of diabetes medication.
• To determine the optimal treatment strategy with these agents, Qaseem and colleagues conducted a comparative safety and effectiveness analysis of studies published between 1966 and April 2010.
• All three recommendations in the guideline are strong and based on high-quality evidence, they said. First among the guidelines: Put patients on oral therapy when diet, exercise, and weight loss have failed to control hyperglycemia.
• There are no data as to the best time start oral therapy; instead, clinicians should take into account other complicating factors including life expectancy, microvascular and macrovascular complications, risk for adverse events related to glucose control, and patient preference, they wrote.
• The patient’s HbA1c target should also be based on an individual risk assessment, though Qaseem and colleagues noted that below 7% is a reasonable goal for many patients.
• They also recommend that the first oral agent should be metformin monotherapy.
• Even though the evidence shows that most drugs reduce HbA1c to a similar degree, metformin appeared to be more effective than the others, they wrote.
• It also conferred the additional benefits of reduced weight and improved cholesterol profiles and was associated with less hypoglycemia, they said.
• It does, however, carry increased risks for gastrointestinal side effects.
• When metformin alone fails to control blood glucose, Qaseem and colleagues recommended using it in combination with another oral agent, noting that there’s no good evidence to support one second-line therapy over another.
• Generic sulfonylureas are the cheapest second-line agents, but adverse effects, especially hypoglycemia, are generally worse with combination therapies that include a sulfonylurea, they cautioned.
• They also warned about well-known risks of heart failure associated with the thiazolidinedione class, which includes the rosiglitazone and pioglitazone.
• Combining more than two agents wasn’t evaluated in this review, they added, and patients with persistent hyperglycemia despite oral therapy may eventually need insulin.
• Qaseem and colleagues noted that low-quality or insufficient evidence made it difficult to draw conclusions about the comparative effectiveness of medications on all-cause and cardiovascular mortality, cardiovascular and cerebrovascular morbidity, and microvascular outcomes.

For further reading log on to
http://www.medpagetoday.com/PrimaryCare/Diabetes/31038