What are the ACP recommendations for use of metformin in the treatment of type 2 diabetes mellitus (DM), and what has big-data research found regarding the addition of other drugs to this therapy?

Updated: Jul 13, 2021
  • Author: Romesh Khardori, MD, PhD, FACP; Chief Editor: George T Griffing, MD  more...
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In January 2017, the American College of Physicians (ACP) released a guideline update recommending the use of metformin as a first-line treatment for type 2 diabetes. The update also recommended consideration of the addition of a drug from one of the following classes—sulfonylureas, thiazolidinediones, dipeptidyl peptidase IV (DPP-4) inhibitors, or selective sodium-glucose transporter–2 (SGLT-2) inhibitors—to metformin when a second oral therapy is thought to be needed to aid glycemic control. However, the second recommendation was graded as "weak," with the evidence of moderate quality, by the ACP. [177, 178]

A study by Vashisht et al that examined data from more than 246.5 million patients found that when used along with metformin therapy for type 2 diabetes, treatment with sulfonylureas, DPP-4 inhibitors, or thiazolidinediones was equally effective in reducing the HbA1c level to 7% or below that of total hemoglobin. However, compared with DPP-4 inhibitors, there was a slightly increased risk of myocardial infarction and eye disorders associated with sulfonylureas. [179, 180]

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