ACP reaffirms metformin for first-line use to treat type 2 diabetes

In updated guidelines published Tuesday in the journal Annals of Internal Medicine, the American College of Physicians (ACP) backed the continued use of metformin as a first-line treatment for adults with type 2 diabetes requiring pharmacologic intervention for glycaemic control. ACP president Nitin Damle said "metformin, unless contraindicated, is an effective treatment strategy because it has better effectiveness, is associated with fewer adverse effects, and is cheaper than most other oral medications." 

The guidelines, which were endorsed by the American Academy of Family Physicians, also recommend that doctors consider adding a sulphonylurea, thiazolidinedione, SGLT-2 inhibitor or DPP-4 inhibitor to metformin if a second oral therapy is required. "Adding a second medication to metformin may provide additional benefits," Damle noted, but "the increased cost may not always support the added benefit, particularly for the more expensive, newer medications." 

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The update is based on findings from a systematic review of randomised, controlled trials and observational studies published through the end of 2015 on the comparative effectiveness of oral therapies for type 2 diabetes, with a focus on metformin, thiazolidinediones, sulphonylureas, SLGT-2 inhibitors and DDP-4 inhibitors. The ACP evaluated outcomes of HbA1c and weight, as well as all-cause mortality, cardiovascular and cerebrovascular morbidity and mortality, retinopathy, nephropathy, and neuropathy, and harms.

SGLT-2 inhibitors include Johnson & Johnson's Invokana (canagliflozin), AstraZeneca's Farxiga (dapagliflozin), and Eli Lilly and Boehringer Ingelheim's Jardiance (empagliflozin), whose indication was recently expanded by the FDA to include reducing the risk of cardiovascular death in adults with type 2 diabetes. DPP-4 inhibitors include Merck & Co.'s Januvia (sitagliptin), as well as Eli Lilly and Boehringer Ingelheim's Tradjenta (linagliptin).

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