by Colin Kenny, GP, Dromore
Both NICE and SIGN guidelines for treating type 2 diabetes recommend initiating metformin, and then adding a second-line agent when metformin alone fails to provide adequate glycaemic control. A team of investigators asked if early combination therapy would achieve benefit health outcomes. They searched for randomised controlled trials evaluating initial combination therapy with metformin versus metformin monotherapy in people with untreated type 2 diabetes.
They found 15 randomised controlled trials with a total of 6693 people with type 2 diabetes. In these trials there was a mean baseline HbA1c level of 55–85 mmol/mol (7.2–9.9%) and a mean diabetes duration of 1.6–4.1 years. Drugs that were combined with metformin included thiazolidinediones, insulin secretagogues, dipeptidyl peptidase-4 inhibitors and sodium–glucose cotransporter 2 inhibitors. Compared with metformin alone, combination therapy with metformin provided statistically significant reductions in HbA1c, increases in attainment of an HbA1c goal of less than 53 mmol/mol (7%) and reductions in fasting plasma glucose.
These results suggest that there is a potential benefit of initial combination therapy on glycaemic outcomes in diabetes compared with metformin monotherapy across a wide range of baseline HbA1c levels.
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