Metformin treatment in patients with diabetes decreases the necessity for follow-up intensification treatments, according to a study published in the online issue of JAMA Internal Medicine. The study is entitled “Initial Choice of Oral Glucose-Lowering Medication for Diabetes Mellitus: A Patient-Centered Comparative Effectiveness Study” and was performed by Seth A. Berkowitz, M.D., M.P.H., of Brigham and Women’s Hospital and Harvard Medical School, Boston, and colleagues.
To understand how the choice of initial drug treatment for lowering glucose levels in patients with type 2 diabetes affects the necessity of a follow-up treatment intensification and also hypoglycemia, diabetes-related emergency department visits, or cardiovascular events, a team of researchers analyzed data from a group of 15,516 patients who were on oral glucose-lowering medication for four years (from July 2009 to June 2013).
From the pooled diabetic patients, four different drugs were administered — metformin (57.8%), sulfonylurea therapy (23%), thiazolidinediones (6.1%), and DPP-4 inhibitors (13.1%).
The authors found that patients receiving metformin treatment exhibited a decreased necessity of a second treatment intensification when compared to other treatments. Specifically, they found second oral medication requirements in 24.5% of metformin-treated patients, 37.1% in sulfonylurea, 39.6% in thiazolidinedione and 36.2% in DPP-4 inhibitors-treated patients. Additionally, a higher percentage of patients required a later insulin treatment in all medications when compared to metformin (5.1% against 9.1%, 5.6% and 6.2% for sulfonylurea, DPP-4 inhibitor and thiazolidinediones, respectively). None of the alternatives to metformin resulted in decreased risks for hypoglycemia, emergency department visits or cardiovascular events, with the latter found to increase in sulfonylurea treatment.
In a related commentary, Jodi B. Segal, M.D., M.P.H., and Nisa M. Maruthur, M.D., M.H.S., of Johns Hopkins University School of Medicine, Baltimore, commented, “Berkowitz and colleagues assert that there is little comparative effectiveness evidence to guide initial selection of therapy for diabetes mellitus. They, therefore, conducted this rigorous study to determine effects attributable to initial oral glucose-lowering agents. This meticulously conducted study, however, adds modestly to what is already known on this topic. Existing evidence is strong on the use of metformin as first-line therapy. Although it is true in some patients that the need to add an additional medication is due to their imperfect adherence to diet and exercise or adherence to the first prescribed drug, in many other patients, it reflects the expected progression of disease and worsening insulin sensitivity and declining β-cell function. Reframing the addition of medication as a necessary step for wellness and health maintenance may go a long way toward patient acceptance of intensification as an unfortunate but necessary part of good self-care.”
