Is it time to stop using sulfonylureas

10:25 am Health Care

Is it time to stop using sulfonylureas?

The American College of Physicians has detailed a guideline regarding use of oral agents in type 2 diabetes entitled “Oral Pharmacologic Treatment of Type 2 Diabetes Mellitus: A Clinical Practice Guideline From the American College of Physicians.”

Earlier guidelines

  • AACE/ACE guideline: metformin is probably best, but you can start with whatever you want,
  • for sulfonylurea.
  • ADA: start with metformin and then add either SU, TZD or insulin.

ACP’s three recommendations

  • Recommendation 1: use medications in patients diagnosed with type 2 diabetes when lifestyle modifications are not working.
  • Recommendation 2: Start with metformin in most patients with type 2 diabetes
  • Recommendation 3: Add a second agent when metformin alone is not enough.

Physicians, after starting on metformin, can choose a second agent based on properties of those specific agents that may be beneficial to a particular patient (i.e. GLP-1 analogues for overweight patients), avoid agents with unwanted side effects (i.e. not using TZDs in patients with fluid overload) as well as other factors such as cost and patient preference.

  1. The evidence shows that most diabetes medications reduced HbA1c levels to a similar degree.
  2. Metformin was more effective than other medications as monotherapy as well as when used in combination therapy.
  3. The risk for hypoglycemia with sulfonylureas exceeds the risk with metformin or thiazolidinediones.
  4. Physicians should start with metformin, then add something else (TZD, DPP4, GLP-1, SGLT-2 -when available), but probably not sulfonylurea, since it clearly causes more hypoglycemia then anything else.
  5. SUs are effective, but not good medications.  They cause significant hypoglycemia. They cause weight gain. The “burn out” the pancreas.  All of the others do not cause hypoglycemia.
  6. All except for TZD’s are weight neutral or cause weight loss.
  7. All the other appear to preserve beta cell function.
  8. The only reason to use SU’s in 2012 is due to cost.
  9. Sulfonylureas should today be used only as 3rd or 4th line agent.

Comments are closed.