Best Practice to Manage Patients with Type 2 Diabetes with an HbA1c Between 6.5 and 7.5

Background and introduction

Type 2 diabetes is a disease with a dramatic rise in its incidence and prevalence.1 The majority of patients do not reach the treatment goals with metformin therapy during the course of type 2 diabetes. Type 2 diabetes progresses over time and requires an escalation of therapeutic efforts as metabolic control deteriorates.2 Metformin—according to most national and international guidelines—is the first-line drug due to its efficacy, its effect on insulin resistance, its weight neutrality, its pharmacological profile, and the lack of risk for causing hypoglycemia. In the United Kingdom Prospective Diabetes Study (UKPDS), patients with newly diagnosed type 2 diabetes treated with metformin had the most favorable outcome.3 Therefore, in a joint treatment recommendation by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD), metformin was recommended as a first-line drug.4 Following this initial pharmacological monotherapy step, the escalation of antidiabetic treatment has many options for second-line combinations. These options are discussed in this manuscript. As a basis for this manuscript—besides stating national and international evidence-based guidelines—a literature search in PubMed, Scopus, and Embase was performed to retrieve preclinical and prospective randomized controlled clinical trial data of the antidiabetic agents. On the basis of these data, a comparison of the antidiabetic treatment combinations is made.

Abstract

The majority of patients with type 2 diabetes do not reach the treatment goals with metformin therapy during the progress of the disease. Therefore, an escalation of therapeutic efforts is required as metabolic control deteriorates. Metformin is the first-line drug due to its efficacy, its effect on insulin resistance, ist weight neutrality, its pharmacological profile, and the lack of risk for causing hypoglycemia. Following this initial pharmacological monotherapy step, the escalation of antidiabetic treatment has many options for second-line combinations. These options are discussed in this manuscript. As a basis for this manuscript besides stating national and international evidence-based guidelines a literature search in PubMed, Scopus, and Embase was performed to retrieve preclinical and prospective randomized controlled clinical trial data of the antidiabetic agents. On the basis of these data, a comparison of the antidiabetic treatment combinations is made.

Keywords

type 2 diabetes, oral antidiabetics, sulfonylureas, glinides, DPP-4 inhibitors, GLP-1 receptor agonists, insulin therapy