‘Safety more important than efficacy’ in HbA1C reduction

PHILADELPHIA — Primary care physicians have a variety of pharmacologic options to reduce HbA1C in patients with diabetes, but safety is more important than reaching a specific glycemic target, according to a speaker at the American College of Physicians Internal Medicine Meeting.

“Ten years ago, we only cared about efficacy and bringing HbA1C down as much as possible,” Guillermo Umpierrez, MD, FACP, FACE, professor of medicine and director of the Clinical Research and Metabolism Center at Emory University School of Medicine, said in a presentation. “In the last 10 years, because of multiple studies showing that hypoglycemia is associated with high risk of hospitalizations, complications and death, safety has overcome efficacy. How much to reduce HbA1C depends on safety,” which should be considered in terms of the individual patient.

Umpierrez first addressed the controversial guidelines for the “ideal” glycemic target as set by the American Diabetes Association, the American Association of Clinical Endocrinologists and the ACP, emphasizing that none of them are appropriate for every patient.

The range of medical options for managing diabetes includes metformin, sulfonylureas, GLP1-RAs and SGLT2 inhibitors, all of which have benefits but also have specific risks for certain patients, Umpierrez said.

Metformin should always be first-line, but can be detrimental to patients with impaired renal function and congestive heart failure, he said. Sulfonylureas must be used with caution in patients with hepatic and renal dysfunction and its cardiovascular safety is uncertain.

The two medications that should be considered for patients with a history of heart failure or stroke are GLP1-RAs and SGLT2 inhibitors, which both provide substantial cardioprotective benefits. Unfortunately, according to Umpierrez, lack of insurance and high cost prevents them from being commonly used, with GLP1-RAs costing between $600 and $900 a month and SGLT2 inhibitors costing more than $400 a month.

“If you put into balance safety and efficacy there is no question safety is much more important,” Umpierrez concluded. “Hopefully, some day, we can [increase use of GLP1-RAs and SGLT2 inhibitors] when they become generic.” – by Melissa J. Webb

Reference:

Umpierrez G. Diabetes care with oral and other noninsulin agents: what you need to know. Presented at: ACP Internal Medicine Annual Meeting. April 11-13, 2019; Philadelphia.

Disclosure: Umpierrez reports no relevant financial disclosures.