A differing opinion on the ACP's new diabetes treatment guidelines
Pharmacotherapy and combination therapy may be a better alternative to the ACP's diabetes treatment guidelines.
I was terribly disappointed to read “ACP releases updated guidelines for oral pharmacologic treatment of type 2 diabetes.” As a Fellow of the American College of Physicians, I am dismayed to see the recommendations given by the ACP.
The recommendation to provide metformin in patients with type 2 diabetes “who need pharmacological therapy to improve glycemic control”—graded as strong recommendation; moderate-quality evidence—is incorrect, and it causes a disservice in treating the epidemic we have with type 2 diabetes where “clinical inertia” is so common.
We know from the UK Prospective Diabetes Study and other studies that therapeutic lifestyle changes alone fail in the great majority of patients. As a result of these older studies and the NIH-sponsored Diabetes Prevention Program, the American Diabetes Association recommends therapeutic lifestyle changes even in prediabetes. The recommendation of giving it only after therapeutic lifestyle changes fail is archaic and does not help improve care. The opposite is true.
The second recommendation is not much better. As a second oral agent (combination therapy with metformin), the ACP recommends prescribing equally either sulfonylureas, thiazolidinediones, sodium-glucose cotransporter 2 inhibitors, or dipeptidyl peptidase 4 inhibitors.
This recommendation is given even when it is well known that sulfonylureas can cause weight gain and hypoglycemia, particularly in the elderly with an increased number of hospitalizations. Also, the literature supports that sulfonylureas not only cause hypoglycemia and weight gain but also have a high rate of cardiovascular mortality when compared with other agents.
Finally, the FDA's approval of Jardiance (empagliflozin) as an agent—the only agent thus far to improve cardiovascular mortality—was not mentioned in the guidelines, and all oral agents were lumped together at the same level.
I am very familiar with the article by Qaseem et al in the Annals of Internal Medicine, which published these recommendations.
I can criticize the studies chosen and the methodology, but this is not the place. I am also perfectly aware, as are all healthcare providers and patients, of the high cost of branded medications, all insulins, and all paraphernalia necessary to treat diabetes.
I want to stress the need to change the way we treat diabetes. Instead of waiting for the A1c to be high or stay high causing organ damage, “chasing” A1cs, we need to be more proactive and use pharmacotherapy and combination therapy early in the disease. Continuing a slow step-up approach, can only result in mismanagement of patients, with half of our US patient population not treated at an A1c goal of < 7%.
Continuing to under treat diabetes can only perpetuate the tremendous economic and social burden of the disease.
I have published an article precisely proposing to change this paradigm. The ACP's recommendations propose archaic and inappropriate approaches for management of diabetes. — Joel Zonszein, MD, CDE, FACP, FACE.
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