Initial Oral Glucose-Lowering Medications: Comparing Classes, Effectiveness

the MPR take:

While the American Diabetes Association and the American College of Physicians recommend metformin as the initial pharmacologic agent for glucose-lowering therapy in type 2 diabetes, long-term data comparing metformin to newer classes of glucose-lowering medications is limited. A study in JAMA Internal Medicine sought to determine the effect of the initial oral glucose-lowering agent class on subsequent treatment intensification and short-term adverse clinical events (including cardiovascular events, emergency department visits, and hypoglycemia). Patients initially prescribed metformin were significantly less likely to require treatment intensification vs. those initially taking sulfonylureas, thiazolidinediones, or DPP-4 inhibitors. Sulfonylureas, thiazolidinediones, and DPP-4 inhibitors were not associated with a lower risk of short-term adverse clinical events compared to metformin; sulfonylureas were associated with an increased risk of cardiovascular events and hypoglycemia. Because only 57.8% of patients in the study began treatment with metformin despite the recommendations, the authors encourage a wider use of this glucose-lowering therapy as an initial pharmacologic agent.

Although many classes of oral glucose-lowering medications have been approved for use, little comparative effectiveness evidence exists to guide initial selection of therapy for diabetes mellitus.