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ACP Guideline on Type 2 Diabetes Recommends Oral Pharmacology as Second-line Therapy
Metformin Suggested For Most Patients Who Do Not Respond to Lifestyle Measures
By Matt Brown
- add oral pharmacologic therapy for patients with type 2 diabetes in whom lifestyle modifications fail to adequately improve hyperglycemia;
- prescribe monotherapy with metformin for initial pharmacologic therapy to treat most patients; and
- add a second agent to manage patients with persistent hyperglycemia when lifestyle modifications and metformin fail to control hyperglycemia.
The evidence review focused on the following key questions:
- The American College of Physicians (ACP) has issued a guideline recommending oral pharmacologic therapy -- typically, with metformin -- for patients with type 2 diabetes when lifestyle modifications fail to improve hyperglycemia.
- If metformin fails to produce the desired result, the guideline recommends adding a second agent.
- In adults 18 or older with type 2 diabetes, what is the comparative effectiveness of these treatment options for the intermediate outcomes of glycemic control, weight or lipids?
- In adults 18 or older with type 2 diabetes, what is the comparative effectiveness of these treatment options in terms of the following long-term clinical outcomes: all-cause mortality, cardiovascular mortality, cardiovascular and cerebrovascular morbidity, retinopathy, nephropathy, and neuropathy?
- In adults 18 or older with type 2 diabetes, what is the comparative safety of these treatment options in terms of the following adverse events and side effects: hypoglycemia, liver injury, congestive heart failure, severe lactic acidosis, cancer, severe allergic reactions, hip and nonhip fractures, pancreatitis, cholecystitis, macular edema or decreased vision, and gastrointestinal side effects?
- Do safety and effectiveness of these treatment options differ across subgroups of adults with type 2 diabetes, in particular for adults 65 or older, in terms of mortality, hypoglycemia, and cardiovascular and cerebrovascular outcomes?
Using this system, all three recommendations were graded as "strong" -- that is, benefits of the intervention clearly outweigh risks and burden -- and were based on high-quality evidence.
The AAFP is expected to review the guideline for possible endorsement.