https://steemit.com/steemstem/@rsc227/medical-practice-question-2
Answer: D
The treatment most likely to achieve the greatest reduction in hemoglobin A1c level is metformin plus a sodium-glucose transporter-2 inhibitor.
Explanation:
Most diabetes medicines have similar efficacy in reducing hemoglobin A1c levels. Evidence from a 2011 review showed no difference between metformin, sulfonylureas, or thiazolidinediones regarding their reduction of hemoglobin A1c levels. This review also showed no difference between thiazolidinediones and sulfonylureas. Additionally, the latest guideline recommend that although all oral diabetes medications reduce hemoglobin A1c levels, the dipeptidyl peptidase-4 (DPP-4) inhibitors were inferior to metformin and sulfonylureas in achieving this outcome.
Combination therapies that include metformin were superior to metformin alone in decreasing hemoglobin A1c levels. According to the 2017 ACP guidelines, “head-to-head comparisons of various combination therapies showed that metformin plus an SGLT2 inhibitor was superior to metformin plus a DPP-4 inhibitor or metformin plus a sulfonylurea in reducing hemoglobin A1c levels, although the CGC (Clinical Guidelines Committee) felt that these differences were of dubious clinical importance.”
The increased cost of combination therapy may not be worth any added benefit, particularly for the more expensive, newer medications like DPP-4 and SGLT2 inhibitors. Metformin is less expensive and has with fewer side effects. It does not result in weight gain.
Reference:
Qaseem A, Barry MJ, Humphrey LL, Forciea MA; Clinical Guidelines Committee of the American College of Physicians. Oral pharmacologic treatment of type 2 diabetes mellitus: a Clinical Practice Guideline Update from the American College of Physicians. Ann Intern Med. 2017;166:279-290. PMID: 28055075