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Gliptins are ‘good alternative’ for weight loss in patients with diabetes

Gliptins should be used more widely in patients with diabetes as they are associated with less weight gain and fewer hypoglycaemic episodes than sulfonylureas, say researchers.

In findings that could lead to a complete rewrite of the current NICE algorithm for diabetes treatment, a meta-analysis of 27 reports found newer drugs had more beneficial effects on weight loss in diabetes.

NICE guidelines currently suggest using metformin first-line and gliptins as alternatives to using sulphonylureas second-line, but only if there is a considerable risk for hypoglycaemia or sulphonylureas are contraindicated or not tolerated.

This recommendation is based on studies carried out before 2009, and the authors of this meta-analysis found current evidence suggests gliptins should be used as a routine second line treatment to meformin and incretins may be suitable for patients targeting weight loss.

The international group of researchers looked at randomised controlled trials of diabetes treatments involving 7,100 adults and found adding gliptins to metformin lowered HbA1c in a similar way to sulphonylureas and glitazones, with mean differences of 0.07 and 0.09.

But patients taking gliptins and metformin lost more weight compared with adding sulfonylurea or glitazones, with differences of -1.92 and -2.96 respectively.

In most trials comparing gliptins with sulfonylureas as add-on therapy to metformin, the risk for hypoglycaemia was higher in the group treated with a sulfonylureas.

Study lead Professor David Matthews, professor of diabetic medicine at the University of Oxford, said they were also a ‘good alternative' to older treatments.

He said: ‘DPP-4 inhibitors can be used as second line treatment in patients with type 2 diabetes who do not achieve their glycaemic targets with metformin alone, but questions about their long term safety still remain to be answered from ongoing trials.'

He also pointed out their data showed gliptins were inferior as a second-line treatment to GLP-1 agonists, both at reducing HbA1c and weight loss, and incretins could be considered for patients wanting to lose weight.

Dr Colin Kenny, a GP in County Down and a committee member of the Primary Care Diabetes Society, said the study should help GPs to prescribe gliptins according to the latest evidence.

‘This is the first study of its type, and I think it's important as it helps clinicians decide where DPP-4 inhibitors fits in with type 2 diabetes treatment regimens.'

He added that he believed the cost of gliptins was an issue: ‘The cost differential of DPP-4 inhibitors compared with other drugs is stopping them from being more widely used, as is a lack of long-term safety data, though this will emerge over the next few years.'

BMJ 2012;344:e1369

 

Weight loss compared with gliptins

Metformin  +1.50*

Sulfonylureas  (plus metformin) -1.92**

Pioglitazone  (plus metformin) -2.96**

Incretins  (plus metformin) +1.56**

*compared with gliptins as monotherapy

**compared with gliptins and metformin

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