Amir Qaseem, MD, PhD, MHA; Michael J. Barry, MD; Linda L. Humphrey, MD, MPH; Mary Ann Forciea, MD; for the Clinical Guidelines Committee of the American College of Physicians *
Note: Clinical practice guidelines are “guides” only and may not apply to all patients and all clinical situations. Thus, they are not intended to override clinicians' judgment. All ACP clinical practice guidelines are considered automatically withdrawn or invalid 5 years after publication or once an update has been issued.
Disclaimer: The authors of this article are responsible for its contents, including any clinical or treatment recommendations.
Financial Support: Financial support for the development of this guideline comes exclusively from the ACP operating budget.
Disclosures: Dr. Barry reports grants, personal fees, and nonfinancial support from Informed Medical Decisions Foundation and Healthwise, both nonprofits, outside the submitted work. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M16-1860. All financial and intellectual disclosures of interest were declared and potential conflicts were discussed and managed. Drs. Boyd, Iorio, and Vijan were recused from voting on this guideline because of active intellectual conflicts. Dr. Manaker was recused from voting on this guideline because of an active indirect financial conflict. A record of disclosures and management of conflicts of interest is kept for each Clinical Guidelines Committee meeting and conference call and can be viewed at www.acponline.org/clinical_information/guidelines/guidelines/conflicts_cgc.htm.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer and Johnson & Johnson.
Requests for Single Reprints: Amir Qaseem, MD, PhD, MHA, American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106; e-mail, email@example.com.
Current Author Addresses: Dr. Qaseem: American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106.
Dr. Barry: Massachusetts General Hospital, 50 Staniford Street, Boston, MA 02114.
Dr. Humphrey: Oregon Health and Science University, 3710 Southwest U.S. Veterans Hospital Road, Portland, OR 97201.
Dr. Forciea: University of Pennsylvania Health System, 3615 Chestnut Street, Philadelphia, PA 19104.
Author Contributions: Conception and design: A. Qaseem, M.J. Barry, L.L. Humphrey, N. Fitterman.
Analysis and interpretation of the data: A. Qaseem, M.J. Barry, L.L. Humphrey, N. Fitterman, D. Kansagara.
Drafting of the article: A. Qaseem.
Critical revision for important intellectual content: A. Qaseem, M.J. Barry, L.L. Humphrey, D. Kansagara.
Final approval of the article: A. Qaseem, M.J. Barry, L.L. Humphrey, M.A. Forciea, N. Fitterman, C. Horwitch, D. Kansagara, R. McLean, T. Wilt.
Statistical expertise: A. Qaseem.
Administrative, technical, or logistic support: A. Qaseem.
Collection and assembly of data: A. Qaseem.
The American College of Physicians (ACP) developed this guideline to present the evidence and provide clinical recommendations on oral pharmacologic treatment of type 2 diabetes in adults. This guideline serves as an update to the 2012 ACP guideline on the same topic. This guideline is endorsed by the American Academy of Family Physicians.
This guideline is based on a systematic review of randomized, controlled trials and observational studies published through December 2015 on the comparative effectiveness of oral medications for type 2 diabetes. Evaluated interventions included metformin, thiazolidinediones, sulfonylureas, dipeptidyl peptidase-4 (DPP-4) inhibitors, and sodium–glucose cotransporter-2 (SGLT-2) inhibitors. Study quality was assessed, data were extracted, and results were summarized qualitatively on the basis of the totality of evidence identified by using several databases. Evaluated outcomes included intermediate outcomes of hemoglobin A1c, weight, systolic blood pressure, and heart rate; all-cause mortality; cardiovascular and cerebrovascular morbidity and mortality; retinopathy, nephropathy, and neuropathy; and harms. This guideline grades the recommendations by using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system.
The target audience for this guideline includes all clinicians, and the target patient population includes adults with type 2 diabetes.
ACP recommends that clinicians prescribe metformin to patients with type 2 diabetes when pharmacologic therapy is needed to improve glycemic control. (Grade: strong recommendation; moderate-quality evidence)
ACP recommends that clinicians consider adding either a sulfonylurea, a thiazolidinedione, an SGLT-2 inhibitor, or a DPP-4 inhibitor to metformin to improve glycemic control when a second oral therapy is considered. (Grade: weak recommendation; moderate-quality evidence.) ACP recommends that clinicians and patients select among medications after discussing benefits, adverse effects, and costs.
Qaseem A, Barry MJ, Humphrey LL, Forciea MA, for the 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. doi: 10.7326/M16-1860
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Published: Ann Intern Med. 2017;166(4):279-290.
Published at www.annals.org on 3 January 2017
Cardiology, Coronary Risk Factors, Diabetes, Endocrine and Metabolism, Guidelines.
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Print ISSN: 0003-4819 | Online ISSN: 1539-3704
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