Reduction of diabetes treatment options via patient-specific factors
Author: Bernice Ford, 2021 PhD Candidate, Florida Agricultural and Mechanical University, College of Pharmacy and Pharmaceutical Sciences
The many diabetes treatment options for hypoglycemic drugs can make an individualized pharmacological approach to treatment difficult.
The American Diabetes Association recommends metformin as the initial treatment for type 2 diabetes. As long as it is tolerated and there are no contraindications, metformin should be continued and other hypoglycemic agents may be used. added to the metformin regimen if necessary. The decision-making process for adjunct therapy options should be guided using a patient-centered approach. Patient-specific characteristics to consider when initiating combination therapy include cardiovascular co-morbidities, risk of hypoglycemia, impact on weight, cost, side effect profile, and patient preferences. . With such a range of drugs available for the management of type 2 diabetes, ambiguity in approach to pharmacological treatment is common among clinicians. Treatment options that postulate maximum glycemic control, vascular improvement, and mortality benefits should be selected in each patient.
A clinical research and evidence-based medicine unit in Thessaloniki, Greece aimed to provide a comprehensive overview of the currently available literature. Therefore, the team conducted a systematic review and network meta-analysis to compare the efficacy of 21 hypoglycemic drugs used in the management of type 2 diabetes. This review included data from randomized trials with a duration of intervention of at least twenty-four weeks. Hypoglycemic potential, vascular outcomes and mortality have been evaluated in more than 320,470 patients.
Data were synthesized from 453 trials to evaluate 21 hypoglycemic interventions from 9 different drug classes. The randomized controlled trials analyzed included the following interventions: 134 exploring monotherapies, 296 exploring adjunct therapies with metformin, and 23 comparing monotherapies with adjunct therapies with metformin.
In treatment-naÃ¯ve patients with low cardiovascular risk, there was no clinically significant difference in reductions in hemoglobin A1c when metformin was compared with other treatment options, excluding dipeptidyl peptidase inhibitors. -4 (DPP-4). The most substantial decreases in hemoglobin A1c levels were obtained when metformin-based treatments with supplemental insulin and glucagon-like peptide-1 receptor agonists (GLP-1 RA) were used. . In 298 trials that evaluated disease-modifying metformin therapy in patients at low cardiovascular risk, there was no clinically significant difference between treatment options in terms of vascular outcomes and mortality. Patients with increased cardiovascular risk receiving maintenance therapy with metformin have also been analyzed in 21 clinical trials. Oral semaglutide, empagliflozin, liraglutide, dapagliflozin and extended-release exenatide have been shown to reduce all-cause mortality, while semaglutide, empagliflozin and liraglutide further reduce cardiovascular mortality in this disease. patient population. In addition, the risk of stroke has been reduced with subcutaneous semaglutide and dulaglutide. Hospitalizations for heart failure and end-stage renal disease were lower with sodium-glucose-2 co-transporter inhibitors (SGLT-2). Subcutaneous semaglutide increased diabetic retinopathy, while canagliflozin showed a higher frequency of amputations.
Other drug-specific factors to consider before starting treatment in adults with type 2 diabetes are cost, kidney effects, and side effect profiles. The cost of metformin is relatively low; however, it is contraindicated in patients with estimated glomerular filtration rate (eGFR) less than 30 ml / min / 1.73 m2. Gastrointestinal side effects are also familiar with metformin and glucagon-like peptide-1 receptor agonists (GLP-1 RA). The cost of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) is neutral, and their initiation or dose escalation should be performed with caution due to the potential risk of acute kidney injury. The glucagon-like peptide-1 receptor specific agonist, liraglutide, has been shown to benefit in the progression of diabetic renal failure. Sodium-glucose-2 co-transporter inhibitors (SGLT-2) are expensive, increase low density lipoprotein (LDL) cholesterol levels, and require renal dose adjustments. Canagliflozin, empagliflozin and dapagliflozin demonstrate marked progression in diabetic renal failure. Canagliflozin has an FDA approved indication for the management of chronic kidney disease and a black box warning for the risk of amputation. Despite the need for renal dose adjustment, thiazolidinediones (TZDs) are generally not recommended for use in patients with renal impairment due to the potential for fluid retention. Insulin provides the highest antihyperglycemic efficacy. Human insulin is inexpensive with both subcutaneous and inhaled routes of administration. Insulin analogues are expensive and are only available subcutaneously. Therefore, lower doses of insulin are needed with reduced estimated glomerular filtration rates (eGFRs). The insulin dosage is titrated / reduced according to clinical responses. Reactions at the injection site and the risk of hypoglycaemia should also be monitored.
When treatment goals are not met in patients with type 2 diabetes, escalation of treatment should not be delayed. Instead, re-evaluation of regimen and adherence should take place every three to six months, with appropriate adjustments made to incorporate other beneficial drug options based on patient-specific factors.
- Maximum glycemic control is achieved with the concomitant use of metformin with insulin or glucagon-like peptide-1 receptor agonists (GLP-1 RA).
- In patients at low cardiovascular risk, all diabetes treatment options have been shown to be equally effective in terms of vascular outcomes.
- Combination therapy with metformin has been shown to reduce all-cause mortality in type 2 diabetes.
References for âReducing the Scope of Diabetes Treatment Options Using Patient-Specific Factorsâ:
Tsapas A, Avgerinos I, Karagiannis T, et al. Comparative efficacy of hypoglycemic drugs for type 2 diabetes. Ann Med Intern. June 2020: doi: 10.7326 / M20-0864
Pharmacological Approaches to Blood Glucose Treatment: Standards of Medical Care for Diabetes â 2020 Diabetic treatments. 2020; 43
Bernice Ford, 2021 PharmD candidate, Florida Agricultural & Mechanical University, College of Pharmacy and Pharmaceutical Sciences