What treatments for type 2 diabetes decrease the likelihood of patient-oriented outcomes?
This study further separates the effect of diabetes treatments on blood glucose levels and important outcomes. SGLT-2 inhibitors and GLP-1 receptor agonists reduce all-cause and cardiovascular mortality, as well as other cardiac-related problems. Older treatments, including insulin, do not affect long-term outcomes. In what might result in a shake-up in our approach to type 2 diabetes, metformin was not found to be more effective than standard treatment to prevent important outcomes, which echoes previous findings and may cause it to be removed as a cornerstone of treatment 1a-
Plan de l'etude:
Meta-analysis (randomized controlled trials)
These investigators searched 3 databases, including Cochrane Central, and identified 816 English-language randomized controlled studies (N = 471,038 participants) that compared 2 or more medications for type 2 diabetes. The researchers followed PRISMA criteria for reporting. Approximately one-quarter of the studies had a high risk of bias, usually due to lack of masking (62%). The researchers conducted a network meta-analysis, which compares all medications against one another by combining both direct and indirect evidence across all the studies. All the studies were short-term, with a median duration of 6 months. Sodium glucose cotransporter-2 (SGLT-2) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists reduce all-cause mortality to a small extent compared with usual treatment. They also reduce death due to cardiovascular causes, the likelihood of nonfatal myocardial infarction, and admission for heart failure. They also have a demonstrated rate of adverse effects as compared with usual care. Finerenone (Kerendia) probably reduces, as compared with usual care, admissions for heart failure and end-stage kidney disease. Tirzepatide (Mounjaro) is associated with greatest amount of weight loss.
Just as important, this analysis clarifies which treatments do not have an overall benefit on patient-oriented outcomes. The older treatments, including insulin, do not affect mortality or hospitalizations, and the thiazolidinediones increase the likelihood of being admitted for heart failure. Metformin, the cornerstone of treatment in most guidelines, may not have a benefit over standard treatment.
Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine