A recent NEJM «clinical case» focuses upon treatment options in a common practice Type 2 diabetic patient. As the article states, it is an overwhelming worldwide public health problem that threatens both duration and quality of life. In addition, economic repercussions upon health systems is very important. Because of every reason mentioned above, I dare to put forward some statements
contained in the article that have a major importance.
First: metformin is the cornerstone of type 2 diabetes treatment. There’s no surprise at this point. Cheap, efficacious and evidence-based.
Second: Although there is general agreement on the first-line use of metformin in most patients with type 2 diabetes, evidence is lacking to inform the most appropriate choice of second-line agents. So, you do not have strong data to decide if this or that is actually better.
Third: the long-term safety of GLP-1–receptor agonists, DPP-IV inhibitors, and other newer agents and their effects on diabetic complications, including cardiovascular disease, need to be determined. In other words, if you do not have a definitive proof of advantage, more time in the market is indeed an advantage. Older tools are well known tools.
Fourth: A joint statement by the American Diabetes Association and the European Association for the Study of Diabetes recommends that for patients with glycemia that is not adequately controlled with lifestyle changes and metformin, “well-validated” therapies, including sulfonylureas or basal insulin, should be used, followed by more intensive insulin therapy, as needed; pioglitazone, GLP-1 agonists, and other medications discussed above are considered “less-well-validated” options.
Last, but no least: at the top of the article we find some figures ‘bout the diabetes pandemics. In Spain, we’ve got recent strong data that point to roughly 14% of the general population reached (7% known). That means, approximately, 2-3% of the general population in 2nd-3rd line treatments. The recent introduction of gliptins, responsible for only a mild deviation of the market, caused a nearly doubling in the expense for antidiabetic oral drugs in Andalusia, Spain (slideshare presentation, Spanish).
So, authorities should provide for more strict regulations, due to current concerns related to public health systems sustainability and the actual possibility of inefficient management of a limited budget.