November 6, 2014

Metformin Not First-Line Treatment

Even though this is interesting, it still does not tell us why many doctors are not using metformin as the first-line treatment for type 2 diabetes. The results of a new US study show that only 58% of individuals with type 2 diabetes were started on metformin as their first oral glucose-lowering medication. This is despite the fact that this drug is widely recommended as the initial therapy of choice in numerous diabetes guidelines.

I can say that insulin can be an excellent choice when the doctors have waited too long to diagnose type 2 diabetes, but this isn't even mentioned in the people receiving other medications. All were other oral medications - sulfonylureas, thiazolidinediones, and dipeptidyl peptidase 4 (DPP-4) inhibitors. The Study period was from July 2009 to end of June 2013 and who filled a second prescription for a medication in the same class within 90 days of the first.

Senior author Dr Niteesh K Choudhry, from the division of pharmacoepidemiology at Harvard Medical School, Boston, MA explained it this way, "These findings have significant implications for quality of life and medication costs."

In an accompanying commentary, Drs Jodi B Segal and Nisa M Maruther (Johns Hopkins University School of Medicine, Baltimore, Maryland) agree with these conclusions. "This meticulously conducted study… adds modestly to what is already known on this topic. First-line therapy should be metformin in patients without contraindications."

Without contraindications” is the key and this, along with quality of life and medication costs are the reasons for metformin being considered in first-line therapy. Occasionally some doctors are persuaded by drug representatives to use other medications and money may be the reason these doctors start with the more expensive drugs.

Dr. Choudhry stated, “Although the study did not examine the specific prescribers involved, with this type of national insurer the "vast majority" of physicians would have been primary-care providers (general internists) seeing patients in routine care settings.”

A total of 15 516 patients were said to have met the inclusion criteria, of whom 8964 (57.8%) started therapy with metformin. Sulfonylurea treatment was the first drug in 23% of cases, 6.1% began treatment with thiazolidinediones, and 13.1% with DPP-4 inhibitors.

Patients prescribed metformin were less likely to require treatment intensification compared with those who used the other medications: 24.5% who started on metformin required a second oral medication, compared with 37.1% of patients prescribed a sulfonylurea, 39.6% who began with a thiazolidinedione, and 36.2% given a DPP-4 inhibitor first. Sulfonylureas, in particular, were associated with more adverse cardiovascular events and hypoglycemia.”

I am aware of many patients that are started on metformin, extended release (ER), that have been doing well because they followed directions and consumed it with food or at meal time and had few of the gastrointestinal problems. Others have started on regular metformin and have encountered the gastrointestinal discomfort. Most are okay in a few weeks and a few have been unable to tolerate this. I don't know anyone using the liquid metformin, but it is available.

In addition to the above link, this topic has received wide press. One more link if you are interested is this by Healio Endocrine Today.

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