Patrick J Phillips
Stephen M Twigg
The range of oral hypoglycaemic agents (OHAs) has increased from one insulin sensitiser
(metformin) and one class of insulin secretagogues (sulphonylureas) with the addition
of further class of insulin secretagogues (glitinides), a further class of insulin sensitisers
(glitazones) and two new classes: an alpha glycosidase inhibitor and glucagon-like
peptide agents. Recent data has influenced the recommended sequence and usage of
OHAs and glycaemic targets.
This article reviews the recent evidence in type 2 diabetes about the pros and cons of
oral hypoglycaemic agents and the benefits and costs of intensive glycaemic control. It
suggests a stepwise approach to glycaemic control with OHAs according to the evidence
base currently available.
Before 2008, the recommended glycaemic management was healthy lifestyle, metformin
and sulphonylurea if tolerated, then rosiglitazone or insulin. Pioglitazone could be used
with insulin therapy but not as triple therapy. In 2007 and 2008 data about glitazones
demonstrated a potential increased risk of myocardial infarction with rosiglitazone
and increased risk of heart failure, peripheral fractures and macular oedema with both
pioglitazone and rosiglitazone. In 2009 a new class of hypoglycaemic agents, glucagonlike
peptide 1 agents, became available. Three trials published in 2009 failed to show
a statistically significant reduction in cardiovascular events with intensive glycaemic
management compared to conventional management. The current recommended target
for HbA1c is <7% but higher or lower targets may be appropriate for individual patients.
Before 2008 the recommended steps in glycaemic management were:
- healthy lifestyle
- metformin, sulphonylurea if tolerated, and finally
- consideration of a glitazone or insulin.1
The oral hypoglycaemic agents (OHAs) controlling postprandial glycaemia were not often used – meal time acarbose (Glucobay) slowing carbohydrate digestion or repaglinide (Novo Norm) transiently increasing prandial insulin secretion.
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