What are the first-line and alternative treatment options for type 2 diabetes (T2D) in the Philippines, considering accessibility and affordability of medications such as metformin, gliclazide (Sulfonylurea), and Sodium-Glucose Cotransporter 2 (SGLT2) inhibitors like empagliflozin?

First-Line and Alternative Treatment Options for Type 2 Diabetes in the Philippines

Metformin and SGLT2 inhibitors like empagliflozin should be the first-line treatment for most patients with type 2 diabetes in the Philippines, with sulfonylureas like gliclazide as an affordable alternative when cost is a major barrier. 1

First-Line Treatment Options

Metformin

• Recommended as the preferred initial pharmacologic agent for type 2 diabetes treatment 1
• Benefits include:
  • Low cost and wide availability in the Philippines 2
  • Weight-neutral effects and low risk of hypoglycemia 3
  • Potential reduction in cardiovascular events and mortality 1
• Dosing considerations:
  • Start at lower doses and titrate up to reduce gastrointestinal side effects 3
  • Extended-release formulation improves tolerability and allows once-daily dosing 3
  • Adjust dose when eGFR <45 mL/min/1.73 m² and discontinue when <30 mL/min/1.73 m² 1

SGLT2 Inhibitors (e.g., Empagliflozin)

• Recommended as first-line treatment alongside metformin for patients with T2D 1
• Benefits include:
  • Cardiovascular and renal protection 1
  • Weight loss effects 1
  • Reduction in heart failure hospitalization risk 1
• Limitations in the Philippine context:
  • Higher cost compared to metformin and sulfonylureas 1
  • Should not be initiated when eGFR <30 mL/min/1.73 m² 1

Alternative Treatment Options (Based on Accessibility and Affordability)

Sulfonylureas (e.g., Gliclazide)

• Affordable alternative when cost is a major barrier 1
• Considerations:
  • Effective glucose-lowering capability 1
  • Higher risk of hypoglycemia compared to metformin and SGLT2 inhibitors 1
  • Associated with weight gain 1
  • May be preferred in patients who cannot afford SGLT2 inhibitors 1

GLP-1 Receptor Agonists

• Recommended as additional therapy when needed for glycemic control 1
• Benefits:
  • Cardiovascular risk reduction in patients with established CVD 1
  • Weight loss effects 1
• Limitations in the Philippine context:
  • Higher cost compared to oral agents 1
  • Injectable administration (except for oral formulations) 1

DPP-4 Inhibitors

• Alternative when hypoglycemia avoidance is important 1
• Considerations:
  • Weight-neutral effects 1
  • Lower risk of hypoglycemia 1
  • Higher cost than metformin and sulfonylureas 1
  • Not recommended for concurrent use with GLP-1 RAs 1

Treatment Algorithm Based on Patient Factors

For Most Patients with T2D

1. Start with metformin (if no contraindications) 1
2. Add SGLT2 inhibitor if affordable and eGFR ≥30 mL/min/1.73 m² 1
3. If glycemic targets not met, add GLP-1 RA (preferred) or other agents based on patient factors 1

For Patients with Financial Constraints

1. Start with metformin 1, 2
2. Add sulfonylurea (e.g., gliclazide) if additional therapy needed 1
3. Consider insulin if further intensification required 1

For Patients with Cardiovascular Disease

1. Start with metformin plus SGLT2 inhibitor (empagliflozin preferred) 1
2. Add GLP-1 RA if further glycemic control needed 1

For Patients with Chronic Kidney Disease

• For eGFR ≥30 mL/min/1.73 m²: Metformin (with dose adjustment if eGFR <45) plus SGLT2 inhibitor 1
• For eGFR <30 mL/min/1.73 m²: Consider insulin or other agents suitable for reduced renal function 1

Important Considerations for the Philippine Context

• Medication cost is a significant factor affecting treatment adherence in the Philippines 1, 2
• Generic formulations of metformin and sulfonylureas are widely available and affordable 1, 2
• SGLT2 inhibitors and GLP-1 RAs, while offering significant benefits, may be cost-prohibitive for many patients 1
• Regular monitoring of renal function is essential, especially with metformin and SGLT2 inhibitors 1
• Consider extended-release metformin formulations for patients with gastrointestinal intolerance to improve adherence 3