Gojka Roglic, MD, MSc; Susan L. Norris, MD, MPH
Financial Support: Financial support for the development of this synopsis came from the World Health Organization budget.
Disclosures: Dr. Roglic is an employee of the World Health Organization, where she manages the process of guideline development in the field of diabetes. Dr. Norris reports stock ownership in Teva Pharmaceutical Industries, Athenahealth, and CVS Health. She is an employee of the World Health Organization, where she helps to oversee the quality of WHO guidelines. She is also a member of the GRADE Working Group. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M18-1149.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Darren B. Taichman, MD, PhD, Executive 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 Proctor & Gamble, Pfizer, and Johnson & Johnson.
Corresponding Author: Gojka Roglic, MD, MSc, World Health Organization, 20 Avenue Appia, Geneva 1211, Switzerland; e-mail, firstname.lastname@example.org.
Current Author Addresses: Drs. Roglic and Norris: World Health Organization, 20 Avenue Appia, Geneva 1211, Switzerland.
Author Contributions: Analysis and interpretation of the data: G. Roglic, S.L. Norris.
Drafting of the article: G. Roglic.
Critical revision of the article for important intellectual content: S.L. Norris.
Final approval of the article: G. Roglic, S.L. Norris.
The World Health Organization developed these guidelines to provide guidance on selection of medicines for treatment intensification in type 2 diabetes and on use of insulin (human or analogue) in type 1 and 2 diabetes. The target audience includes clinicians, policymakers, national diabetes program managers, and medicine procurement officers. The target population is adults with type 1 or 2 diabetes in low-resource settings in low- or high-income countries. The guidelines also apply to disadvantaged populations in high-income countries.
The recommendations were formulated by a 12-member guideline development group and are based on high-quality systematic reviews identified via a search of several bibliographic databases from 1 January 2007 to 1 March 2017. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) system was used to assess the quality of the evidence and the strength of the recommendations. The guideline was peer-reviewed by 6 external reviewers.
Give a sulfonylurea to patients with type 2 diabetes who do not achieve glycemic control with metformin alone or who have contraindications to metformin (strong recommendation, moderate-quality evidence).
Introduce human insulin treatment to patients with type 2 diabetes who do not achieve glycemic control with metformin and/or a sulfonylurea (strong recommendation, very-low-quality evidence).
If insulin is unsuitable, a dipeptidyl peptidase-4 (DPP-4) inhibitor, a sodium–glucose cotransporter-2 (SGLT-2) inhibitor, or a thiazolidinedione (TZD) may be added (weak recommendation, very-low-quality evidence).
Use human insulin to manage blood glucose in adults with type 1 diabetes and in adults with type 2 diabetes for whom insulin is indicated (strong recommendation, low-quality evidence).
Consider long-acting insulin analogues to manage blood glucose in adults with type 1 or type 2 diabetes who have frequent severe hypoglycemia with human insulin (weak recommendation, moderate-quality evidence for severe hypoglycemia).
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Guam Regional Medical City Hospital, Guam
September 21, 2018
Benefits, Harms and Cost
It was interesting to read today the WHO recommendation of using a sulfonylurea after metformin, while also reading the article published in JAMA (https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2698083?utm_source=silverchair&utm_medium=email&utm_campaign=article_alert&utm_term=mostread&utm_content=olf-widget_09202018) that showed that even thought effectiveness of the second line choices is not different, SU seem to be associated with a slight higher chance of MI. Is the higher cost of DDP-4 and therefore, potential decreased adherence justifies the possible higher harm risk of SUs? Wondering how to discuss this with my patients from Micronesia.
Roglic G, Norris SL. Medicines for Treatment Intensification in Type 2 Diabetes and Type of Insulin in Type 1 and Type 2 Diabetes in Low-Resource Settings: Synopsis of the World Health Organization Guidelines on Second- and Third-Line Medicines and Type of Insulin for the Control of Blood Glucose Levels in Nonpregnant Adults With Diabetes Mellitus. Ann Intern Med. ;169:394–397. doi: 10.7326/M18-1149
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Published: Ann Intern Med. 2018;169(6):394-397.
Published at www.annals.org on 4 September 2018
Cardiology, Coronary Risk Factors, Diabetes, Endocrine and Metabolism, Guidelines.
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