INITIAL CHOICE OF ORAL MEDICATION TO LOWER GLUCOSE IN DIABETES PATIENTS EXAMINED
Patients diagnosed
with diabetes and initially prescribed metformin to lower their glucose levels
were less likely to require treatment intensification with a second oral
medicine or insulin than patients treated first with sulfonylureas,
thiazolidinediones or dipeptidyl peptidase 4 inhibitors (DPP-4 inhibitors),
according to a study published online by JAMA Internal Medicine
The American
Diabetes Association, the American College of Physicians and guidelines
commissioned by the Agency for Healthcare Research and Quality all advocate
metformin as the initial treatment to lower glucose levels in patients with
type 2 diabetes.
Researchers Seth A.
Berkowitz, M.D., M.P.H., of Brigham and Women's Hospital and Harvard Medical
School, Boston, and colleagues examined the initial choice of a
glucose-lowering medication on the time to subsequent treatment
intensification, as well as hypoglycemia, diabetes-related emergency department
visits or cardiovascular events. The authors used data from a group of 15,516
patients who were insured and had been prescribed an oral glucose-lowering
medication from July 2009 through June 2013.
Of those patients,
8,964 patients (57.8 percent) began diabetes treatment with metformin.
Sulfonylurea therapy was started by 3,570 patients (23 percent), 948 patients
(6.1 percent) began treatment with thiazolidinediones and 2,034 patients (13.1
percent) with DPP-4 inhibitors.
Patients prescribed
metformin were less likely to require treatment intensification compared with
those who used the other medications. While 2,198 patients (24.5 percent)
prescribed metformin required a second oral medication, 37.1 percent of patients
prescribed a sulfonylurea, 39.6 percent prescribed a thiazolidinedione and 36.2
percent prescribed a DPP-4 inhibitor did. A total of 5.1 percent of patients
prescribed metformin later added insulin, while 9.1 percent of patients
prescribed a sulfonylurea, 5.6 percent prescribed a DPP-4 inhibitor and 6.2
percent prescribed thiazolidinediones added insulin.
The alternatives to
metformin also were not associated with a reduced risk of hypoglycemia,
emergency department visits or cardiovascular events. Using a sulfonylurea
appeared to be associated with an increased risk of cardiovascular events.
"Despite
guidelines, only 57.8 percent of individuals began diabetes treatment with
metformin. Beginning treatment with metformin was associated with reduced
subsequent treatment intensification, without differences in rates of
hypoglycemia or other adverse clinical events. These findings have significant
implications for quality of life and medication costs," the study
concludes.
Commentary: Initial
Therapy for Diabetes Mellitus
In a related
commentary, Jodi B. Segal, M.D., M.P.H., and Nisa M. Maruthur, M.D., M.H.S., of
Johns Hopkins University School of Medicine, Baltimore, write: "Berkowitz
and colleagues assert that there is little comparative effectiveness evidence
to guide initial selection of therapy for diabetes mellitus. They therefore
conducted this rigorous study to determine effects attributable to initial oral
glucose-lowering agents."
"This
meticulously conducted study, however, adds modestly to what is already known
on this topic. Existing evidence is strong on the use of metformin as
first-line therapy," they continue.
"Although it is
true in some patients that the need to add an additional medication is due to
their imperfect adherence to diet and exercise or adherence to the first
prescribed drug, in many other patients it reflects the expected progression of
disease and worsening insulin sensitivity and declining β-cell function. …
Reframing the addition of medication as a necessary step for wellness and
health maintenance may go a long way toward patient acceptance of
intensification as an unfortunate but necessary part of good self-care,"
they conclude.
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