Is Metformin the Best First-Line Therapy for Those With Diab
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Several pharmacologic options for type 2 diabetes are available. This review compared the benefits and harms of glucose-lowering drugs in adults with type 2 diabetes.

453 trials assessing 21 antidiabetic interventions from 9 drug classes were included. Interventions included monotherapies (134 trials), add-on to metformin-based therapies (296 trials), and monotherapies versus add-on to metformin therapies (23 trials).

-- There were no differences between treatments in drug-naive patients at low cardiovascular risk.
-- Insulin regimens and specific glucagon-like peptide-1 receptor agonists (GLP-1 RAs) added to metformin-based background therapy produced the greatest reductions in hemoglobin A1c level.
-- In patients at low cardiovascular risk receiving metformin-based background treatment (298 trials), there were no clinically meaningful differences between treatments for mortality and vascular outcomes.
-- In patients at increased cardiovascular risk receiving metformin-based background treatment (21 trials), oral semaglutide, empagliflozin, liraglutide, extended-release exenatide, and dapagliflozin reduced all-cause mortality.
-- Oral semaglutide, empagliflozin, and liraglutide also reduced cardiovascular death.
-- Odds of stroke were lower with subcutaneous semaglutide and dulaglutide. Sodium–glucose cotransporter-2 (SGLT-2) inhibitors reduced heart failure hospitalization and end-stage renal disease.
-- Subcutaneous semaglutide and canagliflozin increased diabetic retinopathy and amputation, respectively.

Conclusively, In diabetic patients at low cardiovascular risk, no treatment differs from placebo for vascular outcomes. In patients at increased cardiovascular risk receiving metformin-based background therapy, specific GLP-1 RAs and SGLT-2 inhibitors have a favorable effect on certain cardiovascular outcomes.

Source: https://www.acpjournals.org/doi/10.7326/M20-0864
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