Does Choice of Second-line Therapy Affect Glycemic Control?
Until 2012, the American Diabetes Association (ADA) recommended lifestyle and metformin as first-line therapy for glycemic management in type 2 diabetes, followed by a sulfonylurea (SU) or insulin for additional A1c reduction.[1] The rationale was that SUs were well validated as a glucose-lowering therapy, even though the risk for hypoglycemia was recognized, along with concerns about increased cardiovascular risk,[2] especially in combination with metformin.[3]
Today, with many more second-line options available, the ADA's new guidelines[4] open the door to whichever therapy is best for the individual patient. But what exactly does that mean?
Khunti and colleagues[5] analyzed data from 10,256 patients who initiated a second-line glucose-lowering therapy after treatment with metformin monotherapy between 2011 and 2014 in Germany and the United Kingdom. The main outcome of interest was change in A1c at 6 months.
The researchers assessed the impact of various factors, including demographics, baseline A1c, time since diabetes diagnosis, and different types of second-line therapy, including SU or dipeptidyl peptidase-4 (DPP-4) inhibitor alone, SU or DPP-4 inhibitor with metformin, and insulin with or without other agents.
Most patients added a therapy to metformin, the most common of which was SU (41%) followed by DPP-4 inhibitor (31%).
