Management of an Adult With Type 2 Diabetes With Antidiabetic Medications: A Case Scenario
Clinical Decision: Unsuccessful Glycemic Control
As a result of this follow-up visit, how do you decide to proceed?
Discussion of Answers:
A. Incorrect. Explanation: Metformin alone in this patient is not achieving glycemic control. Continuing metformin for a longer period of time in the hope that it may eventually improve glycemic control constitutes unwarranted clinical inertia.
B. Incorrect. Explanation: There is high strength of evidence that metformin and second-generation sulfonylureas will similarly lower HbA1c by about 1 absolute percentage point.
C. Incorrect. Explanation: There is moderate strength of evidence that metformin and thiazolidinediones will similarly lower HbA1c by about 1 absolute percentage point.
D. Incorrect. Explanation: There is moderate strength of evidence that metformin lowers HbA1c 0.4% better than the dipeptidyl peptidase-4 (DPP-4) inhibitors.
E. Correct. Explanation: Available evidence indicates there is significant clinical benefit to glycemic control (usually about one percentage point decrease in HbA1c) by combination therapy using two agents with different modes of action. Evidence shows that the combination of metformin/thiazolidinediones (high strength of evidence), metformin/second-generation sulfonylureas (high strength of evidence), and metformin/dipeptidyl peptidase-4 inhibitors (moderate strength of evidence) are better than metformin monotherapy at reducing HbA1c, with an absolute difference of about 1%.
Keywords: clinical decision | glycemic control | clinical inertia | combination therapy | monotherapy
- Bennett WL, Wilson LM, Bolen S, et al. Oral Diabetes Medications for Adults With Type Diabetes: An Update. Comparative Effectiveness Review No. 27. (Prepared by Johns Hopkins University Evidence-based Practice Center under Contract No. 290-02-0018.) AHRQ Publication No. 11-EHC038-EF. Rockville, MD: Agency for Healthcare Research and Quality. March 2011. Available at: http://effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productID=644.
- Nathan DM, Buse JB, Davidson MB, et al. Medical management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy: a consensus statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care. 2009;32:193-203.
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