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Metformin showed best results for first-line treatment of type 2 diabetes
Bennett WL. Ann Intern Med. 2011;In press.
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Metformin, in combination or alone, appears to be the top choice for first-line treatment of type 2 diabetes because it demonstrates the best risk-benefit profile vs. other diabetes drugs, according to new data.
Researchers performed a comprehensive systematic review of 140 randomized clinical trials and 26 observational studies that analyzed the safety and efficacy of various diabetes medications, including metformin, second-generation sulfonylureas, thiazolidinediones, meglitinides, dipeptidyl peptidase-4 (DPP-4) inhibitors and glucagon-like peptide-1 receptor agonists. Studies that examined the drugs used alone or in combination were included.
Results indicated that most medications used as monotherapy yielded comparable decreases in HbA1c (about one absolute percentage point on average throughout the course of a study). Metformin alone, however, lowered HbA1c more than DPP-4 inhibitors alone, and any type of combination therapy reduced HbA1c by about one absolute percentage point more than monotherapy.
Weight loss with metformin was a mean 2.5 kg more vs. TZDs and sulfonylureas. Other data also showed that combination metformin and GLP-1 agonists induced greater weight loss than other combination therapies, but the researchers said evidence supporting this finding was weak.
When compared with pioglitazone, sulfonylureas and DPP-4 inhibitors, metformin also significantly lowered LDL. Further, the drug decreased triglycerides and moderately raised HDL.
The researchers reported that sulfonylureas raised the risk for hypoglycemia fourfold vs. metformin monotherapy. Combination treatment with metformin and a sulfonylurea also had a sixfold higher risk for hypoglycemia than combination metformin and TZDs.
Analysis of other adverse events revealed that risk for congestive heart failure was higher with TZDs than with sulfonylureas. Risk for bone fractures was also higher with TZDs than with metformin alone or metformin combined with sulfonylurea. Diarrhea, however, was more commonly associated with metformin than with other medications.
“Although the long-term benefits and harms of diabetes medications remain unclear, the evidence supports use of metformin as a first-line treatment agent,” the researchers wrote.
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