From the Guidelines
The American College of Physicians recommends metformin as the first-line pharmacologic therapy for type 2 diabetes mellitus, with a strong recommendation based on moderate-quality evidence. This guideline is supported by the study published in the Annals of Internal Medicine in 2017 1. The target audience for this guideline includes all clinicians, and the target patient population includes adults with type 2 diabetes.
Key Recommendations
- Metformin is recommended as the initial pharmacologic agent for type 2 diabetes, due to its efficacy in improving glycemic control, as well as its relatively favorable side effect profile and cost-effectiveness.
- When a second oral therapy is considered, options include sulfonylureas, thiazolidinediones, SGLT-2 inhibitors, or DPP-4 inhibitors, with the choice depending on patient-specific factors such as benefits, adverse effects, and costs 1.
- Lifestyle modifications, including diet, exercise, and weight management, are also crucial components of diabetes care.
Rationale
The management of type 2 diabetes mellitus is complex and requires a multifaceted approach. The American College of Physicians guideline provides a framework for clinicians to make informed decisions about pharmacologic therapy, taking into account the latest evidence and patient-specific factors. By prioritizing metformin as the first-line therapy, clinicians can help improve glycemic control and reduce the risk of complications associated with diabetes.
Additional Considerations
While the guideline provides a general framework for managing type 2 diabetes, it is essential to consider individual patient factors, such as comorbidities, medication tolerability, and patient preferences, when making treatment decisions. Regular monitoring of HbA1c levels, as well as screening for complications, is also critical to ensuring optimal diabetes care. The American Diabetes Association standards of medical care in diabetes, as outlined in the 2016 synopsis 1, also emphasize the importance of individualized care and comprehensive management of diabetes.
From the FDA Drug Label
1 INDICATIONS AND USAGE Metformin hydrochloride tablets are indicated as an adjunct to diet and exercise to improve glycemic control in adults and pediatric patients 10 years of age and older with type 2 diabetes mellitus.
DOSAGE AND ADMINISTRATION ACTOS should be taken once daily without regard to meals. The management of antidiabetic therapy should be individualized. Ideally, the response to therapy should be evaluated using HbA1c which is a better indicator of long-term glycemic control than FPG alone.
The guidelines for diabetes management (dm) include:
- Diet and exercise as an adjunct to medication, such as metformin, to improve glycemic control 2
- Individualized management of antidiabetic therapy, with response to therapy evaluated using HbA1c 3
- Monitoring of patients for adverse events related to fluid retention, and careful evaluation of change in HbA1c after initiation of therapy or dose increase 3
From the Research
Guidelines for Diabetes Management
- The management of type 2 diabetes mellitus (T2DM) involves lifestyle modifications and pharmacological interventions 4.
- Current guidelines recommend long-term weight loss of 5% to 7% of body weight and 150 minutes of at least moderate-intensity physical activity per week for most patients with prediabetes and diabetes 5.
- Techniques to assess and facilitate adherence to these lifestyle changes can be practical in primary care, including assessing patients' readiness to work toward change and addressing patients' conviction and confidence 5.
Pharmacological Interventions
- Pioglitazone is a valuable component of combination therapy for T2DM, improving glycemic control with an extremely low incidence of hypoglycemia 6.
- Pioglitazone can be administered in combination with metformin, sulfonylureas, exenatide, dipeptidyl peptidase 4 (DPP-4) inhibitors, or insulin 6.
- The combination of DPP-4 inhibitors and pioglitazone in type 2 diabetes has theoretical consideration and therapeutic potential, with clinical trials showing reduction in average hemoglobin A1c (HbA1c) levels 7.
Lifestyle Modifications
- Healthy eating and increased physical activity can prevent or delay the onset of diabetes mellitus and facilitate diabetes management 5.
- Lifestyle goals and targets should be tailored to patients' preferences and progress while building confidence in small steps 5.
- Screening for diabetes-related attitudes, expectations, and quality of life, and addressing psychosocial factors, both favorable and unfavorable, can facilitate the likelihood of success 5.
Combination Therapy
- Pioglitazone plus sulfonylurea reduces postload glycemia and increases composite insulin sensitivity index (CISI) more than metformin plus sulfonylurea 8.
- Pioglitazone plus metformin also decreases postload glycemia and increases CISI more than gliclazide plus metformin 8.
- The combination of sitagliptin or vildagliptin with pioglitazone can be a useful therapeutic approach in patients with type 2 diabetes who cannot tolerate metformin or a sulfonylurea 7.