We now have 12 classes of drugs for the treatment of diabetes. Choosing which ones to use is not always straightforward.
It’s easy for type 1 diabetes: insulin.
Type 2’s have more options. Metformin is the unanimous #1 pick. After that, it’s murky.
I recently reviewed the American Diabetes Association’s Standards of Medical Care in Diabetes – 2014. A type 2 treatment algorithm therein mentions only six of the 12 available classes. This gives you an idea of expert consensus on which drugs to use. The classes are biquanides (metformin), sulfonylureas, thiazolidinediones, DPP-4 inhibitors, GLP-1 agonists, and insulins. This is one reason you don’t see much use of bromocriptine and colesevelam.
The American Association of Clinical Endocrinologists also have a type 2 diabetes treatment algorithm, published in 2013. It also addresses prediabetes and overweight/obesity. You’ll see some of the other classes mentioned. It’s confusing because of abbreviations.
Believe it or not, most doctors want to do what’s right for our patients. We want positive results that reduce suffering and death. Does Big Pharma influence the production of guidelines and individual physician drug choices? If I had to guess, I’d say yes. But I don’t have the resources to investigate that in any depth. I know without a doubt that if I recommend a drug and the patient has a bad outcome, it helps me win the malpractice lawsuit if I’ve recommended a guideline-approved drug. Other docs know that, and it’s one of many factors that influence drug choice. We also consider cost (if you bring it up), convenience, patient preference, what our local colleagues are doing, what other illnesses the patient has, potential adverse drug effects, etc.
We don’t know the long-term adverse effects of many of these drugs. That’s why I favor doing as much as reasonably possible with lifestyle modification, such as diet and exercise, before stacking up multiple drugs. If you need drugs, and most with diabetes do, lifestyle modification can help you minimize drug use.
Steve Parker, M.D.