Oral medications for diabetes

Oral medications for diabetes

The American College of Physicians has published a new guideline for the "Oral Pharmacologic Treatment of Type 2 Diabetes Mellitus" in the February 21 issue of the Annals of Internal Medicine. The guideline suggests that if diet, exercise, and weight loss fail to improve hyperglycemia, oral drug therapy should be initiated. Most diabetes medicines lower HbA1c levels to a similar degree, and none of the medications have compelling outcomes data to suggest one class is superior to another class with regard to cardiovascular or all-cause mortality. But metformin "was more effective than other medications as monotherapy as well as when used in combination therapy with another agent for reducing HbA1c levels, body weight, and plasma lipid levels (in most cases)." Therefore, the guideline recommends that clinicians prescribe monotherapy with metformin for initial pharmacologic therapy for most patients with type 2 diabetes. Metformin is effective at reducing glycemic levels and is not associated with weight gain. Additionally, the drug helps reduce LDL cholesterol and triglyceride levels. Metformin is contraindicated in patients with impaired kidney function, decreased tissue perfusion or hemodynamic instability, liver disease, alcohol abuse, heart failure, and any conditions that might lead to lactic acidosis. For patients with persistent hyperglycemia despite metformin, a second drug should be added. No good evidence supports one combination over another. Sulfonylureas have a higher risk for hypoglycemia and thiazolidinediones are associated with an increased risk for heart failure. There are no specific recommendations for the use of the glinides (nateglinide or repaglinide) or the DPP-4 inhibitors (linagliptin, saxagliptin, or sitgliptin). The guideline does not make a recommendation for combinations of more than two oral agents. Injectables, such as the various insulins and GLP-1 analogs, were not addressed in the guideline. (Ann Intern Med 2012; 156:218-231).