Memorandum

American College of Physicians releases updated guidelines for treating type 2 diabetes with oral agents – January 23, 2017

The American College of Physicians (ACP) recently published revised guidelines for oral pharmacologic treatment of type 2 diabetes, updated from the previous 2012 guidelines. The guidelines offer two major recommendations:

(i) Clinicians should prescribe metformin as a first-line pharmacotherapy to improve glycemic control; and

(ii) Clinicians should consider adding a sulfonylurea, TZD, SGLT-2 inhibitor, or DPP-4 inhibitor on top of metformin to further improve glycemic control.

The ACP reviewed relevant literature on metformin, sulfonylureas, TZDs, SGLT-2 inhibitors, and DPP-4 inhibitors, evaluating each drug class on the basis of A1c-lowering efficacy, weight effects, systolic blood pressure effects, heart rate, all-cause mortality, cardiovascular (CV) morbidity and mortality, retinopathy, nephropathy, neuropathy, and other safety concerns. We’re beyond disappointed that the guidelines put all oral medications – including sulfonylureas! – on equal footing. This seems unambitious – we’re sure we don’t have the full story and we haven’t been able to find it, so if we are mistaken in this view, please let us know the other side of this! Notably, the article makes no mention of possible cardioprotection associated with SGLT-2 inhibitors, which is a glaring omission considering that the ADA’s recently-published 2017 Standards of Care explicitly recommend SGLT-2 inhibitor empagliflozin (Lilly/BI’s Jardiance) for type 2 diabetes patients at high-risk of CV death. As well, GLP-1 is not mentioned at all – although it is not an oral med, we believe there may have been some reference to it, at least acknowledging this class. In the era of CV outcomes trials, as the bar for advanced diabetes drugs continues to rise – demanding more than just blood glucose-lowering – we’d hope that professional organizations and guideline-writing committees would do their part in spreading awareness of CV benefits in addition to CV safety signals. The ACP guidelines offer a most cursory, basic algorithm for type 2 diabetes management, and in our view, clinical recommendations should do much more to support busy providers in treating this complicated chronic disease.

 

-- by Payal Marathe, Helen Gao, and Kelly Close