Administration (FDA)-approved therapy
for use in type 1 diabetes. It has been
shown to induce weight loss and lower
insulin dose; however, it is only indicated
in adults. Concurrent reduction
of prandial insulin dosing is required to
reduce the risk of severe hypoglycemia.
Investigational Agents
Metformin
Adding metformin to insulin therapy may
reduce insulin requirements and improve
metabolic control in overweight/obese
patients with poorly controlled type 1
diabetes. In a meta-analysis, metformin
in type 1 diabetes was found to reduce
insulin requirements (6.6 U/day, P ,
0.001) and led to small reductions in
weight and total and LDL cholesterol but
not to improved glycemic control (absolute
A1C reduction 0.11%, P 5 0.42) (13).
Incretin-Based Therapies
Therapies approved for the treatment of
type 2 diabetes are currently being evaluated
in type 1 diabetes. Glucagon-like
peptide 1 (GLP-1) agonists and dipeptidyl
peptidase 4 (DPP-4) inhibitors are
not currently FDA approved for those
with type 1 diabetes, but are being studied
in this population.
Sodium–Glucose Cotransporter 2 Inhibitors
Sodium–glucose cotransporter 2 (SGLT2)
inhibitors provide insulin-independent
glucose lowering by blocking glucose
reabsorption in the proximal renal tubule
by inhibiting SGLT2. These agents provide
modest weight loss and blood pressure
reduction. Although there are two FDAapproved
agents for use in patients with
type 2 diabetes, there are insufficient
data to recommend clinical use in type 1
diabetes at this time (14).
PHARMACOLOGICAL THERAPY FOR
TYPE 2 DIABETES
Recommendations
c Metformin, if not contraindicated
and if tolerated, is the preferred
initial pharmacological agent for
type 2 diabetes. A
c In patients with newly diagnosed
type 2 diabetes and markedly symptomatic
and/or elevated blood glucose
levels or A1C, consider initiating
insulin therapy (with or without
additional agents). E
c If noninsulin monotherapy at maximum
tolerated dose does not