This site is intended for health professionals only

At the heart of general practice since 1960

Read the latest issue online

CAMHS won't see you now

Using a glitazone second-line in diabetes 'reduces mortality by 30%'

UK researchers have questioned the current algorithm for diabetes treatment after their study showed using a glitazone second-line with metformin was more effective than adding sulfonylureas at this stage.

Their long-term study in primary care patients found that metformin plus pioglitazone significantly reduced the risk of all-cause mortality by a third, and serious cardiovascular events by over a quarter, when compared to metformin plus a sulfonylurea.

The study retrospectively analysed data of 26,278 patients with type 2 diabetes from the General Practice Research Database who had received metformin monotherapy as their first treatment.

Patients were classified by second-line treatment if they switched within 180 days of ceasing metformin and followed for 10 years.

HbA1c improved significantly with all combinations by a median of 1.0%, bar metformin and DPP4-inhibitors. However, the mean HbA1c did not fall below 7.0% for any of the regimens.

Patients receiving metformin plus pioglitazone had a significant reduction of 29% in all-cause mortality when compared to metformin plus a sulfonylurea.

This combination also significantly reduced the risk of a combined endpoint, defined as the first occurrence of death, myocardial infarction, stroke or cancer by 26%, compared to metformin plus a sulfonylurea.

No significant differences were found with combinations of metformin plus rosiglitazone or metformin plus DPP4-inhibitors when compared with metformin plus a sulfonylurea.

The meformin-pioglitazone combination was significantly better at preventing death, myocardial infarction, stroke or cancer compared with all other regimes, except metformin plus a DPP4-inhibitor.

NICE guidelines currently recommend a sulfonylurea as second-line treatment when metformin fails to adequately control blood glucose, with other therapies third line.

The authors concluded that alternative therapies to metformin plus sulfonylurea may provide superior clinical outcomes.

They concluded: ‘These findings provide some intriguing insights into the optimal approach to intensifying glucose-lowering therapy after the failure of metformin.

‘Data from our study indicates that alternative treatment regimens may provide superior clinical outcomes, in particular metformin plus pioglitazone or metformin plus a DPP4 inhibitor.’

Dr Colin Kenny, a GP in County Dromore and a member of Primary Care Diabetes Society, said: ‘I feel this will be helpful for practices that have cohorts of patients on the metformin-pioglitazone combination.

‘In practice I do consider using pioglitazones or DPP4-inhibitors as second-line over sulfonylureas, but it is not in NICE or SIGN guidance currently – it will be interesting to see if this changes.’


Mortality risk

Sulfonylurea monotherapy – 45% increase

Metformin-pioglitazone – 30% decrease

Meformin + DPP4 – 39% decrease (not significant)

Metformin + Rosiglitazone – 9% decrease (not significant)

*compared with metformin-sulfonylurea

Journal of Clinical Endocrinology and Metabolism 2012, available online 17 October

Related images

  • Advice for diabetes patient

Readers' comments (4)

  • What happened to MI, heart failure, osteoporotic fracture and bladder cancer risk with glitazones? Honestly the evidence changes every week - how are you supposed to keep up? Should the people who sued over avandia pay back the money?

    Unsuitable or offensive? Report this comment

  • Vinci Ho

    It is a bit of Choose and Book situation :
    One school is very keen on pioglitazone and considers that it was flawed the way those side effects were reported .
    The other school is certainly looking at banning glitazones.
    Between glitazones and gliptins , the former is more potent on HBA1c as the latter only lowers the value by 0.75%.......

    Unsuitable or offensive? Report this comment

  • Many of our patients tolerate piog with no problems, and we have seen good results. one of our experienced GP's always tailors the medication to the individual/ and takes into consideration all comorbid factors. Our GP suggests Piog best started earlier in treatment and approx 5 months for optium results.

    Unsuitable or offensive? Report this comment

  • I understood that the glitazones, especially pioglitazone (actos) were a last resort option because they increase the risk of bladder cancer and heart failure. While all medications have side effects, these are more serious because they can be life-threatening.

    Unsuitable or offensive? Report this comment

Have your say