Cutting Costs in Diabetes Care

Arefa Cassoobhoy, MD, MPH


October 04, 2018

Hello. I'm Dr Arefa Cassoobhoy, a primary care internist, Medscape advisor, and senior medical director for WebMD. Welcome to Medscape Morning Report, our 1-minute news story for primary care.

Diabetes is an expensive disease, especially when treatment must be intensified. To address this crisis, the World Health Organization (WHO) has released diabetes treatment guidelines that take the cost of drugs into account. They're applicable for disadvantaged groups in the United States.

Like the American College of Physicians (ACP) type 2 diabetes recommendations, the WHO emphasizes the importance of lifestyle change and the use of metformin as first-line therapies. For second-line therapy, the WHO recommends sulfonylureas, a strong recommendation with moderate-quality evidence.

In an editorial from the ACP,[1] sulfonylureas' effectiveness and low cost are acknowledged, but they say that the risk for hypoglycemia can be an issue that prompts clinicians to choose another second-line agent like an SGLT2 inhibitor, thiazolidinedione, or DPP-4.

While we don't have as much long-term data on these newer agents, emerging research shows benefits worth noting. DPP-4 and SGLT2 inhibitors are linked with weight loss, and some SGLT2 inhibitors may improve cardiovascular outcomes and lower mortality.

For third-line treatment options, the WHO recommends starting human insulin. If that's not a good option, then consider adding a newer agent or a long-acting insulin analog.

Follow Dr Cassoobhoy on Twitter at @ArefaMD


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