Diabetes Drug Choice: No Easy Algorithms

In treating type 2 diabetes, the first drug to use is metformin hydrochloride, a panel of specialists agreed at the American College of Physicians Internal Medicine meeting in San Diego, California.

The tougher question, agreed Diana McNeill, MD (photo), Steven Edelman, MD, and Sue Kirkman, MD, is what other drug or treatment to add.

In a session “Escalating Care in Management of Type 2 Diabetes: Preventing Clinical Inertia,” the physician panelists said many factors enter into drug choices.

“Everyone agrees that metformin is the drug of choice; it’s inexpensive and well-proven, Edelman said, “it also has gastrointestinal side effects, but extended release may help with nausea.”

With dozens of diabetes drugs to choose from—glitazones, DPP4 inhibitors, SGLT2 inhibitors and more--physicians often turn to official guidelines from medical organizations. Many have side effects and it can be a matter of deciding which of those potential negatives are the most important in an individual patient.

Those include hyperglycemia risk, and the effects on weight, often a particular concern for female patients. The use of SGLT2 inhibitors can result in polyuria, and yeast infections in women.

More recently there have been concerns about drugs cause B-12 deficiencies, which Edelman said is an emerging issue with chronic use of metformin.

The problem for clinicians trying to come up with standard protocols in their own practice is that official guidelines can be vague, the panelists agreed.

“The ACP guideline says metformin, then add something else—it’s not very useful,” said Edelman.

In the real world, the panelists agreed, the choice of a second drug often comes down to price.

“It’s partly what you can get your hands on,” Kirkman said, when it comes to patients’ health plans and what drugs are covered.

Even when they are covered, the costs can vary dramatically from pharmacy to pharmacy.

Kirkman said that the American Diabetes Association guidelines recommend pioglitazone for some patients and she had prescribed it to a woman with type 2 diabetes.

“It is expensive but there is a huge variation in the cost of the generic,” she said, “I had a patient who said it was costing her $190 a month, so we called around and found pharmacies charging from $15 to $119.”

Cost is a big factor in patients’ adherence to recommended regimens. If they can’t afford their medications, they tend not to regularly refill their prescriptions, Kirkman said.

“The new insulins are awesome but expensive,” said McNeill.

Panelists disagreed on the benefits of inhaled insulin, which works quickly but is not good in patients with asthma or chronic obstructive pulmonary disease and requires a lung-function test to measure whether patients should take it. “Insulin is a growth factor; inhaling it into the alveoli gives me pause because of cancer,” Kirkman said.

Injectable insulin is getting less popular because of price increases that are putting it out of range for patients with no insurance, Kirkman said.

In a study of refill patterns, using data from Express Scripts, Kirkman said her team had found that men were more likely to get refills on time—possibly because their wives took charge—and that the older patients were and the more different medications they were taking, the more likely they were to fill their prescriptions.

Making lifestyle changes is a cornerstone of therapy, but even there, money can be a factor.

In rural areas, there may be few resources such as good nutrition options and the availability of health clubs that can help patients eat healthier and get regular exercise.

And local customs can be a problem, McNeill added, such as the constant consumption of sugary sweet tea in the South.