Advice on using oral therapy

For patients in whom diet and exercise do not adequately control type 2 diabetes, initiate oral therapy using the following principles:

• Use metformin (unless contraindicated) as a first-line agent for most patients with type 2 diabetes who require medication, because it causes less hypoglycemia and weight gain and may reduce cardiovascular risk. Consider sulfonylureas as first-line agents in patients who are not obese.
• Maximize dosage of an agent before adding additional agents, although escalating doses may be of limited effectiveness.
• Add a sulfonylurea in most patients on metformin requiring a second agent; consider a thiazolidinedione or incretinomimetic drugs in those at risk for hypoglycemia.
• Given minimal differences in efficacy and limited data about long-term outcomes, use combinations of oral agents based on patient preference, clinician familiarity, and consideration of issues such as side effect profiles and costs.
• Consider pharmacologic therapy at the time of diagnosis in patients with severe hyperglycemia (fasting blood glucose >250 to 300 mg/dL) or marked symptoms.
• Consider all of the following factors when making individual treatment decisions: minimization of weight gain, minimization of injections, minimization of patient effort, avoidance of hypoglycemia and minimization of cost.
• Consider adding acarbose, a thiazolidinedione, or a GLP-1 agonist in patients who have not achieved adequate glycemic control on metformin, a sulfonylurea, or a combination of metformin and a sulfonylurea.

This content is from ACP Smart Medicine, the College's new Web-based clinical decision support tool developed specifically for internal medicine physicians. Information about ACP Smart Medicine is online.

Commentary from ACP DiabetesMonthly's physician editor:

The research news in this month's ACP DiabetesMonthly provides even more support for choosing metformin as the initial pharmacologic therapy for type 2 diabetics. It is well established that metformin directly addresses insulin resistance in this population. In contrast to many diabetic therapies that are associated with weight gain, metformin therapy frequently leads to modest weight loss. Hypoglycemia is extremely rare when using metformin monotherapy. This is often an important consideration, particularly in older diabetics with comorbidities. Metformin appears to decrease cardiovascular events compared to other alternatives, and it is relatively well tolerated as long as therapy is started at a low dose and slowly titrated upward. Recent evidence suggests it may improve the prognosis of patients with cancer (see the “Keeping tabs” section in this issue). All this for a bargain-basement price. Can you imagine the direct-to-consumer advertisements we would see if this were a newly patented medication? We will not see these ads, but it is fun to speculate. So practice high-value care and pick metformin as first-line therapy for type 2 diabetics who do not have a contraindication to it.