National Health and Nutrition Examination Surveys Discussion Paper

Discussion Response #2

Based on the ADA guidelines for diabetes, what would be the next plan of action for a patient who cannot utilize metformin monotherapy?

Metformin monotherapy is prescribed for managing types 1 and 2 diabetes as a first-line therapy, dependent on comorbidities, patient-centered treatment factors and management needs. It is considered in addressing insulin resistant diabetes because it is safe, effective, inexpensive, and reduces the risk of cardiovascular events and death. It has beneficial effects on cardiovascular mortality, weight and A1C (Gu et al., 2022). National Health and Nutrition Examination Surveys Discussion Paper

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If the patient has contraindications or intolerant to metformin monotherapy, then the use of other glucose-lowering drugs is recommended based on patient factors. The alternatives can be insulin, dipeptidase-4 inhibitors, α-glucosidase inhibitors, glinides, thiazolidinediones, sulfonylureas, sodium–glucose cotransporter 2 inhibitors, and glucagon-like peptide 1 receptor agonists can be prescribed as appropriate initial therapy (Gu et al., 2022). For patients with or at high risk for chronic kidney disease, heart failure, and/or atherosclerotic cardiovascular disease, sodium–glucose cotransporter 2 inhibitors (such as ertugliflozin, empagliflozin, dapagliflozin, canagliflozin and bexaglifloxin) or glucagon-like peptide 1 receptor agonists (such as lixisenatide, liraglutide, semaglutide and exenatide) are recommended as part of the glucose lowering regiment and comorbidities risk reduction (Jacobs et al., 2023).

ADA guidelines recommend a patient-centered approach in choosing the appropriate pharmacological agent with a focus on considering the efficacy and key patient factors, particularly important comorbidities (such as heart failure and chronic kidney disease), hypoglycemia risk, effect on body weight, patient preferences, cost, and side effects. Lifestyle modification that improve health should be emphasized alongside the pharmacologic therapy (Lyu et al., 2022). National Health and Nutrition Examination Surveys Discussion Paper

References

Gu, S., Hu, X., Shi, L., Zhen, X., Sun, X., Huang, M., Gu, Y., & Dong, H. (2022). Choice of Glucose-Lowering Drugs as Initial Monotherapy for Type 2 Diabetes Patients with Contraindications or Intolerance to Metformin: A Systematic Review and Meta-Analysis. Journal of clinical medicine, 11(23), 7094. https://doi.org/10.3390/jcm11237094

Jacobs, J. A., Zheutlin, A. R., Derington, C. G., King, J. B., Pandey, A., & Bress, A. P. (2023). Glucagon-like peptide-1 receptor agonist and sodium-glucose cotransporter 2 inhibitor use among adults with diabetes mellitus by cardiovascular-kidney disease risk: National Health and Nutrition Examination Surveys, 2015-2020. American journal of preventive cardiology, 17, 100624. https://doi.org/10.1016/j.ajpc.2023.100624

Lyu, B., Grams, M. E., Chang, A., Inker, L. A., Coresh, J., & Shin, J. I. (2022). Sodium-Glucose Cotransporter 2 Inhibitors, Glucagon-Like Peptide-1 Receptor Agonists, and Dipeptidyl Peptidase-4 Inhibitors, and Risk of Hospitalization.  National Health and Nutrition Examination Surveys Discussion Paper