Summaries of Must-Read Clinical Literature, Guidelines, and FDA Actions
Guideline for Oral Pharmacologic Treatment of T2D
Ann Intern Med; ePub 2017 Jan 3; Qaseem, et al
The American College of Physicians (ACP) has issued an update of its clinical practice guideline for the oral pharmacologic treatment of type 2 diabetes (T2D). Evaluated interventions included metformin, thiazolidinediones, sulfonylureas, dipeptidyl peptidase-4 (DPP-4) inhibitors, and sodium–glucose cotransporter-2 (SGLT-2) inhibitors. The guideline serves as an update to the 2012 ACP guideline and provides clinical recommendations on the topic, including:
- ACP recommends that clinicians prescribe metformin to patients with type 2 diabetes when pharmacologic therapy is needed to improve glycemic control. (Grade: strong recommendation; moderate-quality evidence)
- ACP recommends that clinicians consider adding either a sulfonylurea, a thiazolidinedione, an SGLT-2 inhibitor, or a DPP-4 inhibitor to metformin to improve glycemic control when a second oral therapy is considered. (Grade: weak recommendation; moderate-quality evidence.) ACP recommends that clinicians and patients select among medications after discussing benefits, adverse effects, and costs.
Qaseem A, Barry MJ, Humphrey LL, Forciea MA, for the Clinical Guidelines Committee of the American College of Physicians. Oral pharmacologic treatment of type 2 diabetes mellitus: A clinical practice guideline update from the American College of Physicians. Ann Intern Med. [Published online ahead of print January 3, 2017]. doi:10.7326/M16-1860.
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The expanding therapeutic options for diabetes has made choosing among available classes of agents challenging for clinicians. The conclusion of this ACP review is essentially the same as that of the American Diabetes Association, which is that metformin should be used as the first-line agent, and then the choice of second-line agent should be individualized based on the characteristics of the medication and needs of the patient.1 Characteristics of medications include efficacy in A1c lowering, risk of hypoglycemia, cost, effect on weight, effect on CV outcomes in patients with established CV disease, as well as other effects including GI side effects, effect on blood pressure, risk of genital mycotic infections, and water retention. —Neil Skolnik, MD