Dr Rick Cutfield is an endocrinologist and general physician currently working at Waitemata District Health Board and Mercy Specialist Centre. He trained in Auckland and USA and was Clinical Director of Diabetes and Endocrinology from 1986-2014. He is a life member of Diabetes NZ and patron of Diabetes NZ (Auckland) and a life member of NZSSD. He has been on many guideline and advisory committees and remains actively involved in teaching and clinical research.
Update On Drugs For Type 2 Diabetes…. A Personalised Medicine Approach
To decide the best approach to manage people with T2 diabetes, and indeed how to set an HbA1c target, it is necessary to consider many factors including a patient’s ability to change lifestyle; age, weight, co-morbidities, cultural and socioeconomic factors and potential drug side effects. The positive effect of some of these drugs on cardiovascular and renal outcomes is now relevant. After lifestyle changes and education, Metformin still remains our first choice. It is safer than many realise even with reduced renal function. The following drugs may be added in the order you see fits best.
The pros and cons of each will be discussed:
• DPP IV-inhibitors; Vildagliptin (in NZ). Weight neutral and no hypoglycaemia with Metformin. Low side effect profile
• Sulphonylureas; Glipizide or Gliclazide. Still useful drugs but with a risk of hypoglycaemia
• Thiazolidinediones; Pioglitazone. Useful in some cases with insulin resistance, and steato hepatitis, but weight gain, osteoporosis and potential fluid retention means careful monitoring
• Alpha-glucosidase inhibitors; Acarbose. Occasionally used in those with high CHO diet, but G.I. intolerance often limits use. May be C.V. protective
• SGLT-2 Inhibitors; Dapagliflozin. Not currently funded in NZ. Especially useful in those with high C.V. risk. Reduces weight, BP and HbA1c and C.V. and renal end points as well as heart failure admissions
• GLP-I Agonists; Once weekly or daily given S.C. Reduce C.V. risk, weight and HbA1c. Expensive.
By inference, modern management of T2DM, including individualised drug programmes to control HbA1c, lipid and BP will require careful education to aid adherence. Despite these increasing drug choices, insulin should not be delayed if HbA1c targets are not met.