Inspiration And Expert Advice: Expert Columns
With Oral Type 2 Meds, Newer Doesn’t Necessarily Mean Better
By Daniel Trecroci
Did you ever get a laugh whenever your parents or grandparents talked about how things were better in the “good old days”? Well, according to a recent study, the “good old days” of oral type 2 medications may actually have been better.
According to data presented in the July 16, 2007 online version of Annals of Internal Medicine, Shari Bolen, MDE, MPH, and colleagues at Johns Hopkins University found that older oral agents (i.e., second-generation sulfonylureas and metformin) have “similar or superior effects on glycemic control, lipids and other intermediate end points compared with newer, more-expensive agents [TZDs like Avandia® and Actos®; alpha-glucosidase inhibitors like Precose® and Glyset®; and meglitinides like Starlix®].”
In addition, Bolen and colleagues found that:
- Metformin decreased LDL cholesterol levels by about 10 mg/dL (.55 mmol/L), whereas other oral agents had no obvious effects on LDL cholesterol levels
- Most agents other than metformin increased body weight by 2.2 to 11 pounds.
- TZDs were the only class that had a beneficial effect on HDL ("good") cholesterol levels but a harmful effect on LDL ("bad") cholesterol levels
- Sulfonylureas and Prandin® were associated with greater risk for hypoglycemia
- TZDs were associated with greater risk for heart failure
In an interview with dLife, Bolen says if you look at the average wholesale price of oral diabetes medications, metformin is about $40 for a three-month supply—approximately $160 annually.
“If you look at the TZDs, they are in the $250 to $300 range for a three-month supply, so you’re looking at an annual cost of upward to $1,200,” says Bolen.
Bolen emphasizes that, despite her study, there are places where the newer oral agents have a place.
“I would use metformin or sulfonylureas first because they are cheaper and just as effective,” says Bolen. “However, there are people who can’t tolerate these meds. If you have someone who is having low blood sugars from sulfonylureas and may be better on an agent with less risk for low blood sugars, that might be somebody who would benefit from one of the newer meds over the older meds.”
Bolen adds that metformin’s side effects of nausea, vomiting, and diarrhea might be another reason for someone to consider another oral agent—despite the fact that those side effects go away usually after a few weeks.
Older Agents Not Stopping Epidemic of Complications
Anne Peters, MD, is a professor of medicine at the Keck School of Medicine at USC and author of the book “Conquering Diabetes.” Peters notes that type 2 diabetes is a progressive disease that the older oral agents have not done a good enough job stopping in its tracks.
“With the older agents, diabetes targets weren't reached and diabetes became the leading cause of blindness, lower-extremity amputation and kidney failure in the United States,” says Peters. “They obviously were useful but not enough.”
Peters notes that insulin is a great drug, but often difficult for providers and patients to use effectively.
“The newer oral agents have helped me immeasurably get patients to reach and maintain target blood sugar levels,’ says Peters. “To lessen the risk of heart attack and stroke, we need to lower blood pressure and lipid levels—not so much a sugar issue.”
Peters says the focus should be on wisely using oral medications, encouraging lifestyle change, knowing of and testing for side effects, and understanding that type 2 diabetes is a progressive disease, requiring multiple different treatments.
“…all of which carry some risk,” says Peters. “But the risk is not as great as the disease.”
Read more of Daniel Trecroci's columns.