New Drugs to Meet Glycemic Targets
Charles P. Vega, MD: Welcome to Medscape's Critical Issues in Diabetes. I'm Chuck Vega, clinical professor of family medicine here at the University of California at Irvine, and I am joined by Dr Anne Peters, professor of endocrinology at the University of Southern California, Keck School of Medicine, and she runs the clinical diabetes programs there.
We previously discussed glycemic targets and lipid management, and today we want to discuss how to get patients to goal for glycemic targets. Some new options in antidiabetes medications have come on the market in the past several years, and as a group, they can be effective. They generally avoid hypoglycemia, which is very important. Some can promote weight loss, which is a tremendous goal for many of our patients with diabetes, but they also have some down sides and associated risks. Let's go through them one by one. I want to get your take on how they can be applied clinically. What are best practices in applying these drugs to patients with type 2 diabetes?
The DPP-4 Inhibitors
First, I would like to talk about the dipeptidyl peptidase-4 (DPP-4) inhibitors. An advantage of these drugs is that they are largely well-tolerated. They can be used with dose modifications in patients with renal disease, which is a big plus because that is a problem we run into with metformin, for example. But these drugs are only modestly-to-moderately effective, and that's one drawback of these drugs. They play well with others, but for a patient with a glycated hemoglobin (A1c) of 11%, they're only going to have so much efficacy, with a reduction of 0.5% to 1%. What's your take on the DPP-4 inhibitors as a class?
Anne L. Peters, MD: First, I need to give a shout-out to metformin because metformin is the single best drug we have for treating type 2 diabetes, and it is what we use in combination with everything else. Metformin has to be the baseline. Yet there are patients who can't take metformin, either because of gastrointestinal (GI) side effect or for renal dysfunction. DPP-4 inhibitors are a gentle next class. They are very well-tolerated, taken once daily. You can use a drug such as linagliptin alone without any dose adjustment in patients with any degree of renal dysfunction. I tend to use them if I need a patient's A1c to go from 7.4% down to 6.8%. I use them for small goals—no hypoglycemia, no weight change. But cost is always an issue.
I often see patients who need more A1c reduction, so I tend to use other agents. But I often use the DPP-4 inhibitors in the frail elderly, especially with renal dysfunction. I have patients with type 2 diabetes who came to me with a creatinine of 2 mg/dL, who were on prandial basal insulin, and I get them off the prandial insulin by giving them a DPP-4 inhibitor and keep them on the basal insulin. If I can use it to simplify a regimen, reduce hypoglycemia, and get people to their goal more easily, I'll do it. But I don't use them in everybody. A thousand different combinations are available, but I tend to start with metformin and add in whatever the next therapy is. If somebody is higher than 7.5%; if the patient needs a bigger drop in A1c, I'm going to use a different agent.
The GLP-1 Receptor Agonists
Dr Vega: Speaking of large A1c reductions, with the glucagon-like peptide-1 (GLP-1) agonists, you can see improved A1c efficacy; plus these agents offer the benefits of weight loss—between 1 kg and 4 kg in most studies. There is an issue with adverse events. Cost is a universal issue for all of these newer agents. Like many newer drugs, they can be more expensive. They do offer certain advantages that may make it worth it. What is your opinion?
Source:http://www.medscape.com
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