2,46 Mb - GuíaSalud

B
B
B
B
Metillinides can play a role in the improvement of glycemic control in patients with nonroutine
daily models (irregular or omitted meals).
Acarbose can be considered an alternative therapy when there is intolerance or contraindication
to the rest of oral anti-diabetic drugs.
Thiazolidinediones should not be used as first option drugs.
Should the use of a glitazone be considered necessary, it is recommended to choose pioglitazone
due to its more favourable safety profile.
Additional trials with morbimortality and long-term safety variables are required to establish
the role of incretins therapy on DM 2.
8.1.3. Combination therapy after inadequate control with
initial monotherapy
In the UKPDS 49 study, three years after the DM 2 diagnose, approximately 50%
of the patients required more than one oral antibiotic to maintain an HbA 1
c below
7%, a percentage which increases up to 75% after nine years (79). Due to a gradual
deterioration of diabetes control, most patients required combined therapies to
maintain long-term glycemic aims.
The combination metformin-sulfonylurea is the association of oral anti-diabetic
drugs with more usage experience; however, it is not yet clear whether the
effect of this association on cardiovascular and total mortality is different to that
of metformin or the sulfonylureas as monodrug as there are no RCTs on this matter.
There are some cohort studies which analyse this issue, but they are adjusted
by the main confusion factors and therefore no conclusions can be settled to take
clinical decisions (111).
As regards glycemic control, the UKPDS 28 study (136) states that in patients
who are not controlled with sulfonylureas, the addition of metformin is
more effective than continuing with the maximum dose of sulfonylureas.
There is no information available on the morbimortality results with the rest
of the oral anti-diabetic combinations (111).
According to a recent SR (111), combined therapies have an additive effect
and manage to reduce HbA 1
c more than monotherapy (1% total reduction).
However, the incidence and severity of the adverse effects also increases, unless
oral anti-diabetic drugs are used in smaller doses.
This SR states that the mild and severe hypoglycaemia frequency is higher
with those combinations which include sulfonylureas in comparison to monotherapy
(absolute risk differences between 8% and 14%) (111).
The combination of metformin with rosiglitazone has a similar mild hypoglycaemia
risk in comparison with the metformin monotherapy; in this treatment
group, no severe hypoglycaemias were detected (111).
Cohort
studies
2+
RCT
1+
RCT
1+
SR of RCT
1+
SR of RCT
1+
SR of RCT
1+
66 CLINICAL PRACTICE GUIDELINES IN THE NHS