WHO released recommendations regarding which medicines should be used for treatment intensification in adult patients with type 2 diabetes as well as the use of analogue or human insulin in type 1 and 2 diabetes.
“The guidelines had two objectives. The first was to consider the use of dipeptidyl peptidase-4 inhibitors, sodium–glucose cotransporter-2 inhibitors, thiazolidinediones, and insulin as second- and third-line treatment for control of hyperglycemia in nonpregnant adults with type 2 diabetes after failure of metformin and sulfonylureas. Glucagonlike peptide-1 analogues were not considered because they are infrequently available in low-income countries,” Gojka Roglic, MD, MSc, and Susan L. Norris, MD, MPH, of WHO wrote.
“The second objective was to provide guidance on use of insulin analogues for type 1 and 2 diabetes. Only insulin analogues for which trial comparisons with human insulin were available were considered,” they continued.
The recommendations, which appeared in Annals of Internal Medicine, state:
- Prescribe a sulfonylurea to patients with type 2 diabetes who have contraindications to metformin or do not reach glycemic control with metformin alone.
- Introduce human insulin treatment to patients with type 2 diabetes who do not reach glycemic control with a sulfonylurea and/or metformin.
- If insulin is unsuitable, a thiazolidinedione, or a sodium–glucose cotransporter-2 inhibitor or a dipeptidyl peptidase-4 inhibitor may also be included.
- Utilize human insulin to manage blood glucose in adults with type 1 diabetes and in adults with type 2 diabetes for whom insulin is indicated.
- Contemplate long-acting insulin analogues to manage blood glucose in adults with type 1 or type 2 diabetes who often have severe hypoglycemia with human insulin.
Linda L. Humphrey, MD, MPH
of the High Value Care Committee of the ACP and colleagues pointed out the major differences between the ACP and WHO guidelines in a related editorial.
“For its guideline, the WHO group ranked glycemic control, an intermediate outcome as opposed to a health outcome, as critical, whereas the ACP guideline committee gave greater weight to quality-of-life issues (such as the burdens of monitoring and injections and the risk for hypoglycemia) in deciding to offer clinicians and patients a choice of several agents for second-line therapy,” they wrote.
“The ACP acknowledged cost in its guidelines as well, but thought that in the United States — where pricing, access, and insurance coverage vary — cost might play a greater or lesser role relative to the risk for hypoglycemia for many patients,” Humphrey and colleagues added, also noting that evidence is lacking to support targeting normal fasting blood glucose levels among persons with type 2 diabetes. – by Janel Miller
Please see the studies for the authors’ relevant financial disclosures.