Dialogue and Diagnosis - American Osteopathic Association

Figure 3. Key benefits and risks of antidiabetic medications
Key benefits and risks of antidiabetic medications: metformin, dipeptidyl peptidase-4 (DPP-4) inhibitors, glucagon-like peptide-1 (GLP-1) receptor
agonists, sulfonylureas, thiazolidinediones, and insulin. Abbreviation: CHF, congestive heart failure. 9
Source: Endocrine Practice: official journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists,
by American College of Endocrinology; American Association of Clinical Endocrinologists, Copyright 2012. Adapted with permission of
Aacecorp Inc.
metformin 1000 mg twice daily. Her
glucose reading improved, however
she quickly learned that if a meal was
delayed, hypoglycemia would ensue.
Within another 3 months, her HbA 1c
level was again below 7%, but she
had gained 5 pounds. She had also
curtailed exercise somewhat because
of her fear of hypoglycemia.
The American Diabetes Associa -
tion (ADA) and the European Association
for the Study of Diabetes
(EASD) 1 have recently updated their
recommend ations for the manage -
ment of hyperglycemia to take a
more holistic approach, encouraging
the individualization of treatment
goals and options for patients with
diabetes mellitus. As previously mentioned,
most patients with T2DM
begin pharmacotherapy with
metformin, but they eventually need
additional medications. Figure 2 summarizes
possible progressions in
therapy after metformin and before
the full use of basal bolus insulin. 1 If
the patient’s HbA 1c target is not
achieved after approximately 3
months of lifestyle treatments and
metformin, 1 of these 5 treatment
options should be considered:
metformin combined with (1) a sulfonylurea,
(2) a thiazolidinedione
(TZD), (3) a dipeptidyl peptidase-4
(DPP-4) inhibitor, (4) a GLP-1
receptor agonist, or (5) basal insulin.
The choice is based on patient and
drug characteristics, with the over -
riding goal of improving glycemic
control while minimizing adverse
effects. Shared decision-making with
the patient may help in the selection
of therapeutic options. 1 Figure 3
summarizes key benefits and risks of
the main classes of antidiabetic medications.
9
Limitations of insulin
secretagogues
One of the biggest concerns with
sulfonylureas is hypoglycemia. Medication
associate hypoglycemia is
likely under-recognized and under -
reported as a cause of morbidity and
mortality. 10-12 Hypoglycemia
adversely affects patients’ quality of
life and may influence adherence to
treatment—and, thus, the success of
the treatment. 13,14 Patients and their
friends, families, and neighbors
should be educated about the signs
and symptoms of hypoglycemia and
its treatment. 15
The use of sulfonylureas results in
a relatively rapid lowering of glucose
levels. However, the use of these
agents is not always successful in
maintaining glucose control over the
long-term. The progressive -cell
failure seen in T2DM results in even-
Dialogue and Diagnosis // September 2012
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