Diabetes Q&A

ACP Releases New Guidelines for Treatment of Type 2 Diabetes

The American College of Physicians has released new a guideline on oral pharmacologic treatment for adults with type 2 diabetes, updating those published in 2012.

The updates are based upon a review of studies published from April 2009 through December 2015 and changes in evidence of low or insufficient to high or moderate quality on metformin, thaizolidinediones, sulfonylureas, dipeptidyl peptidase-4 inhibitors, and sodium-glucose cotransporter-2 inhibitors interventions.
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Among the recommendations:

  • Metformin should be prescribed to patients with type 2 diabetes when pharmacologic therapy is needed to improve glycemic control (moderate-quality evidence, strong recommendation)
  • Sulfonylurea, a thiazolidinedione, a sodium-glucose cotransporter-2 inhibitors, or dipeptidyl peptidase-4 inhibitors should be added to metformin to improve glycemic control when considering second oral therapy (moderate-quality evidence, weak recommendation)

According to the review, metformin is effective at reducing glycemic levels and “metformin may have an advantage over sulfonylurea monotherapy in terms of cardiovascular mortality.” The reviewers recommend metformin as “the drug of choice” for patients with type 2 diabetes unless contraindicated.

Reviewers graded the addition of sulfonylurea, a thiazolidinedione, a sodium-glucose cotransporter-2 inhibitors, or dipeptidyl peptidase-4 inhibitors to metformin therapy as a weak recommendation due to the adverse effects of the drug combinations. Sulfonylurea was associated with increased risk for hypoglycemia and weight gain. Sodium-glucose cotransporter-2 inhibitors are favored as an add-on to metformin therapy, but are associated with increased risk for genital mycotic infections.

The authors concluded that metformin is recommended as the first intervention for patients with type 2 diabetes due to its effectiveness and low cost. The addition of a second agent should be added as a second step and after the harm and benefits are assessed with the patient.

—Melissa Weiss

Reference:

Qaseem A, Barry MJ, Humphrey LL, Forciea MA. Oral pharmacologic treatment of type 2 diabetes mellitus: a clinical practice guidelines update from the American College of Physicians [published online January 3, 2017]. Annals of Internal Medicine. doi:10.7326/M16-1860.