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First-line treatment with metformin for diabetes is associated with significantly less intensification of treatment, and fewer short-term adverse outcomes such as cardiovascular events, emergency department visits, and hypoglycemia, compared with other oral glucose-lowering medications.
A retrospective cohort study of 15,516 patients prescribed an oral glucose-lowering medication found that 25% of patients initially prescribed metformin required a second oral agent, compared with 37% of patients prescribed a sulfonylurea, 40% of those prescribed a thiazolidinedione, and 36% of those prescribed a dipeptidyl peptidase–4 inhibitor, according to a retrospective study published online Oct. 27 (JAMA Intern. Med. 2014 Oct. 27 [doi: 10.1001/jamainternmed.2014.5294]).
While numerous guidelines recommend metformin as the first-line choice of glucose-lowering agents, only 58% of patients started therapy with metformin, with a sulfonylurea the second-most-popular choice, despite its increased risk of adverse cardiovascular events.
“Because underuse of metformin may lead to important harms and costs in the treatment of patients with diabetes, multilevel interventions to increase prescribing quality may be needed,” wrote Dr. Seth A. Berkowitz of Harvard University, Boston, and his colleagues.
The study was supported by an unrestricted grant from CVS Health to Brigham and Women’s Hospital, Boston. One author declared funding from an Institutional National Research Service Award, the Ryoichi Sasakawa Fellowship Fund, and Massachusetts General Hospital. There were no other conflicts of interest declared.
Although the superiority of metformin as a first-line monotherapy is not news, the study investigators’ choice of treatment intensification as its primary outcome was novel, and highlighted something of greater significance to patients than to physicians.
Patients consider treatment intensification as a result of failure. Reframing the addition of medication as a necessary step for wellness and health maintenance may go a long way toward patient acceptance of intensification as an unfortunate but necessary part of good self-care.
Dr. Jodi B. Segal and Dr. Nisa M. Maruthur are with the department of medicine at Johns Hopkins University, Baltimore. These comments are taken from their editorial accompanying Dr. Berkowitz’s article (JAMA Intern. Med. 2014 [doi: 10.1001/jamainternmed.2014.4296]). They reported having no relevant disclosures.
Although the superiority of metformin as a first-line monotherapy is not news, the study investigators’ choice of treatment intensification as its primary outcome was novel, and highlighted something of greater significance to patients than to physicians.
Patients consider treatment intensification as a result of failure. Reframing the addition of medication as a necessary step for wellness and health maintenance may go a long way toward patient acceptance of intensification as an unfortunate but necessary part of good self-care.
Dr. Jodi B. Segal and Dr. Nisa M. Maruthur are with the department of medicine at Johns Hopkins University, Baltimore. These comments are taken from their editorial accompanying Dr. Berkowitz’s article (JAMA Intern. Med. 2014 [doi: 10.1001/jamainternmed.2014.4296]). They reported having no relevant disclosures.
Although the superiority of metformin as a first-line monotherapy is not news, the study investigators’ choice of treatment intensification as its primary outcome was novel, and highlighted something of greater significance to patients than to physicians.
Patients consider treatment intensification as a result of failure. Reframing the addition of medication as a necessary step for wellness and health maintenance may go a long way toward patient acceptance of intensification as an unfortunate but necessary part of good self-care.
Dr. Jodi B. Segal and Dr. Nisa M. Maruthur are with the department of medicine at Johns Hopkins University, Baltimore. These comments are taken from their editorial accompanying Dr. Berkowitz’s article (JAMA Intern. Med. 2014 [doi: 10.1001/jamainternmed.2014.4296]). They reported having no relevant disclosures.
First-line treatment with metformin for diabetes is associated with significantly less intensification of treatment, and fewer short-term adverse outcomes such as cardiovascular events, emergency department visits, and hypoglycemia, compared with other oral glucose-lowering medications.
A retrospective cohort study of 15,516 patients prescribed an oral glucose-lowering medication found that 25% of patients initially prescribed metformin required a second oral agent, compared with 37% of patients prescribed a sulfonylurea, 40% of those prescribed a thiazolidinedione, and 36% of those prescribed a dipeptidyl peptidase–4 inhibitor, according to a retrospective study published online Oct. 27 (JAMA Intern. Med. 2014 Oct. 27 [doi: 10.1001/jamainternmed.2014.5294]).
While numerous guidelines recommend metformin as the first-line choice of glucose-lowering agents, only 58% of patients started therapy with metformin, with a sulfonylurea the second-most-popular choice, despite its increased risk of adverse cardiovascular events.
“Because underuse of metformin may lead to important harms and costs in the treatment of patients with diabetes, multilevel interventions to increase prescribing quality may be needed,” wrote Dr. Seth A. Berkowitz of Harvard University, Boston, and his colleagues.
The study was supported by an unrestricted grant from CVS Health to Brigham and Women’s Hospital, Boston. One author declared funding from an Institutional National Research Service Award, the Ryoichi Sasakawa Fellowship Fund, and Massachusetts General Hospital. There were no other conflicts of interest declared.
First-line treatment with metformin for diabetes is associated with significantly less intensification of treatment, and fewer short-term adverse outcomes such as cardiovascular events, emergency department visits, and hypoglycemia, compared with other oral glucose-lowering medications.
A retrospective cohort study of 15,516 patients prescribed an oral glucose-lowering medication found that 25% of patients initially prescribed metformin required a second oral agent, compared with 37% of patients prescribed a sulfonylurea, 40% of those prescribed a thiazolidinedione, and 36% of those prescribed a dipeptidyl peptidase–4 inhibitor, according to a retrospective study published online Oct. 27 (JAMA Intern. Med. 2014 Oct. 27 [doi: 10.1001/jamainternmed.2014.5294]).
While numerous guidelines recommend metformin as the first-line choice of glucose-lowering agents, only 58% of patients started therapy with metformin, with a sulfonylurea the second-most-popular choice, despite its increased risk of adverse cardiovascular events.
“Because underuse of metformin may lead to important harms and costs in the treatment of patients with diabetes, multilevel interventions to increase prescribing quality may be needed,” wrote Dr. Seth A. Berkowitz of Harvard University, Boston, and his colleagues.
The study was supported by an unrestricted grant from CVS Health to Brigham and Women’s Hospital, Boston. One author declared funding from an Institutional National Research Service Award, the Ryoichi Sasakawa Fellowship Fund, and Massachusetts General Hospital. There were no other conflicts of interest declared.
FROM JAMA INTERNAL MEDICINE
Key clinical point: Metformin as first-line therapy is associated with lower rates of progression, compared with other oral glucose-lowering medications.
Major finding: Around one-quarter of patients started on metformin progressed to a second agent, compared with 37% of patients prescribed sulfonylurea.
Data source: Retrospective cohort study of 15,516 patients prescribed an oral glucose-lowering agent.
Disclosures: The study was supported by an unrestricted grant from CVS Health to Brigham and Women’s Hospital, Boston. One author declared funding from an Institutional National Research Service Award, the Ryoichi Sasakawa Fellowship Fund, and Massachusetts General Hospital. There were no other conflicts of interest declared.
