Reviews evidence of newer medications, recommends adding to metformin
BOSTON April 19, 2024 鈥 The 管家婆心水论坛 (ACP) today released an update of its 2017 guideline with clinical recommendations for the use of newer pharmacological treatments of adults with Type 2 diabetes. The clinical guideline is based on the best available evidence for effectiveness, comparative benefits and harms, consideration of patients鈥 values and preferences, and costs. was published today in Annals of Internal Medicine.
In the updated clinical guideline, ACP recommends adding a sodium-glucose cotransporter-2 (SGLT-2) inhibitor or glucagon-like peptide-1 (GLP-1) agonist to metformin and lifestyle interventions in patients with Type 2 diabetes and inadequate glycemic control. Use SGLT-2 inhibitor to reduce the risk of all-cause mortality, major adverse cardiovascular events, progression of chronic kidney disease, and hospitalization due to congestive heart failure or use GLP-1 agonist to reduce the risk of all-cause mortality, major adverse cardiovascular events, and stroke.
ACP, however, recommends against adding a dipeptidyl peptidase-4 (DPP-4) inhibitor to metformin and lifestyle modifications in adults with Type 2 diabetes and inadequate glycemic control because high-certainty evidence showed that adding a DPP-4 inhibitor does not reduce morbidity or all-cause mortality.
鈥淎s additional pharmacological treatments become available for the treatment of Type 2 diabetes, it鈥檚 critical for us to examine their effectiveness, the harms and benefits as well as costs in order to provide the best treatment for our patients,鈥 said Carolyn J. Crandall, M.D., MS, MACP, Chair, Guidelines Committee. 鈥淎dding a second medication to metformin for patients with inadequate glycemic control may provide additional benefits but the added benefit on important clinical outcomes may be minimal in relation to the high cost, particularly for the more expensive, newer medications.鈥
This clinical guideline is based on a systematic review of the effectiveness and harms of newer pharmacological treatments for Type 2 diabetes. ACP prioritized the following outcomes, which were evaluated using the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach: all-cause mortality, major adverse cardiovascular events, myocardial infarction, stroke, hospitalization for congestive heart failure, progression of chronic kidney disease, serious adverse events, and severe hypoglycemia. Weight loss, as measured by percentage of participants who achieved at least 10% total body weight loss, was a prioritized outcome, but data were insufficient for network meta-analysis and not rated with GRADE.
The updated ACP guideline did not look at the effects of treatment for glycemic control, though this is a common treatment goal. It is known that all included treatments can improve glycemic control in adults with Type 2 diabetes. Instead, the guideline focuses on clinical benefit outcomes, such as whether the treatments improve cardiovascular outcomes.
ACP guidelines emphasize shared decision-making, recognizing that each patient's needs and circumstances are unique. ACP encourages physicians to consider individual patient characteristics like age, comorbidities, and personal preferences when discussing a treatment plan for Type 2 diabetes. SGLT-2s and GLP-1s are costly, but lower cost options (like sulfonylureas) were inferior in reducing all-cause mortality and morbidity. There are currently no generic formulations for GLP-1s and SGLT-2.
The ACP clinical guideline is published with an accompanying visual clinical guideline where a person can interact and visualize the data supporting these recommendations.
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About the 管家婆心水论坛
The 管家婆心水论坛 is the largest medical specialty organization in the United States with members in more than 145 countries worldwide. ACP membership includes 161,000 internal medicine physicians, related subspecialists, and medical students. Internal medicine physicians are specialists who apply scientific knowledge and clinical expertise to the diagnosis, treatment, and compassionate care of adults across the spectrum from health to complex illness. Follow ACP on , , and .
Media Contact: Andrew Hachadorian (Ahachadorian@acponline.org 215-351-2514)