Treatment options following metformin in primary prevention populations with type 2 diabetes: which is the right road to take?
Abstract
According to the most recent ADA/EASD consensus report on the management of hyperglycemia in type 2 diabetes (T2D), agents with proven cardiovascular (CV) or renal benefits should be considered for the management of people with established atherosclerotic vascular disease (ASCVD), heart failure (HF) and/or chronic kidney disease (CKD), irrespectively of their glycated hemoglobin (HbA1c) values [1]. In particular, glucagon-like peptide 1 receptor agonists (GLP-1 RAs) should be preferred when ASCVD predominates. Differently, sodiumglucose cotransporter-2 inhibitors (SGLT-2is) should be the first choice in people with HF and/or CKD, whereas each of the two categories can be added on top of the other, if patients are unable to meet glycemic targets. While the therapeutic algorithm adopts a straight-forward approach in suggesting specific drug classes in individuals within secondary prevention, the second step after metformin in primary prevention populations with T2D is still less well defined. The use of sulfonylureas (SUs) and meglitinides in the daily clinical setting presents specific advantages, given that these agents are inexpensive, rendering them an important choice in a setting of limited financial resources. They also manifest strong hypoglycemic effects, although it is known that these are not sustainable over time. The main concern over their use is that they might induce severe hypoglycemic reactions due to their mechanism of action, given that SUs stimulate…
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