Embargoed news for Annals of Internal Medicine

ACP Recommends Metformin to Treat Type 2 Diabetes Based on Comparative Effectiveness Analysis of Oral Medications

The American College of Physicians (ACP) recommends that clinicians add metformin as the initial drug treatment for most patients with type 2 diabetes when lifestyle modifications such as diet, exercise, and weight loss have failed to adequately improve high blood sugar. ACP also recommends that clinicians add a second drug to metformin when treatment with metformin and lifestyle changes fail to control blood sugar levels. Citing insufficient evidence, ACP does not recommend one class of drug over another as a second medication. ACP developed the guideline based on an analysis of the comparative effectiveness and safety of different classes of oral diabetes drugs approved by the US Food and Drug Administration for the treatment of high blood sugar in people with type 2 diabetes: metformin, sulfonylureas, meglitinides, thiazolidinediones, DPP-4 inhibitors, and GLP-1 receptor antagonists. ACP evaluated the evidence for long-term and intermediate outcomes for blood sugar levels, body weight, cholesterol and triglyceride levels, all-cause mortality, cardiovascular disease and death, neuropathy, and kidney function. "We found that most diabetes medications reduced blood sugar levels to a similar degree," said Amir Qaseem, MD, FACP, PhD, MHA, Director of Clinical Policy at ACP. "However, metformin is more effective compared to other type 2 diabetes drugs in reducing blood sugar levels when used alone and in combination with other drugs. In addition, metformin reduces body weight and improves cholesterol profiles."

Implantable cardioverter-defibrillators (ICDs) have been shown to reduce mortality as primary prevention among persons with myocardial infarction or heart failure and as secondary prevention after cardiac arrest. Current clinical guidelines for ICD use apply to both males and females, yet it is not clear if there are sex differences in patient outcomes. Researchers studied health records for 6,021 women and men in Ontario, Canada who were referred to cardiologists specializing in ICD placement. While both sexes were equally likely to receive an ICD if referred to a cardiology specialist, women were 1.6 times more likely to experience complications after implantation at both early and later follow up points. One of the most common issues was movement of the electrical leads of the ICD, which sometimes required the cardiologists to reposition them. Women also were 31 percent less likely than men to receive appropriate shock and 27 percent less likely to receive appropriate antitachycardia therapy from the device. According to the author of an accompanying editorial, the value of ICDs in women has not been thoroughly studied, as women are underrepresented in research. Gender differences need to be considered for patients referred to ICD therapy.

Current clinical guidelines recommend against routine screening for ovarian cancer. Incidence of ovarian cancer is low, and screening tests have high false-positive rates and low positive predictive values. In addition, there is no proof that screening affects morbidity or mortality rates of ovarian cancer. Regardless, it is believed that physicians continue to screen women for ovarian cancer, putting them at risk for unnecessary follow up tests and surgery. Researchers surveyed 3,200 primary care physicians to determine their adherence to clinical guidelines for ovarian cancer screening. Physicians were given a questionnaire containing a woman's annual examination vignette and questions about ovarian cancer screening. The researchers found the physicians commonly offered screening and were more likely to do so for women at higher than average risk or those who requested testing. Physicians with a personal history of cancer, in solo practice, and with longer time in practice were more likely to offer screening.