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Dipeptidyl peptidase-4 inhibitors for treatment of type 2 diabetes mellitus in the clinical setting: systematic review and meta-analysis

BMJ 2012; 344 doi: (Published 12 March 2012) Cite this as: BMJ 2012;344:e1369

Re: Dipeptidyl peptidase-4 inhibitors for treatment of type 2 diabetes mellitus in the clinical setting: systematic review and meta-analysis

Thanks to the author’s for such an excellent study.
This study still ascertains that Metformin is still the preferred monotheraphy. Metformin has been prescribed for diabetic patients for more than 50 years Hence long term studies and data with Metformin are completely available .Metformin has minimal GI side effects .In most of the patients if started slowly or modified release Metformin is given GI side effects are minimal .Though caution is entertained with Creatinine >130 and eGFr less than 45 , apart from few case reports there are no established studies to prove that metformin taken orally in patients with low eGFr is associated with lactic acidosis .
The study shows say that there was nausea, vomiting with metformin but would be interesting to know the GI side effects and relationship to the dosage of metformin, rather than just metformin started on a low dose
New medications are not always the best , but certainly in terms of DPP4 currently they are second line medication of choice with no weight gain , no hypoglycaemia and minimal side effects in diabetic patients though long term study has not been established and one of the serious side effects cautioned currently with sitagliptin is pancreatitis
Data shows DPP-4 as less effective in controlling HBa1c ,compared to sulphonyl urea However with studies showing increase cardiovascular events with aggressive Hba1c control (ACCORD Trial ) DPP4 are still a matter of choice and the risks of aggressive glycaemic control associated with hypoglycaemia and weight gain, must be weighed against the benefits in each patient with Type 2 diabetes .If someone wants a Legacy Effect obviously control should be aimed more intensively with education , diet and more than just DPP4 inhibitors
It will be also interesting to know whether there have been any significant adverse events in long term study in animal models as we had cancer scare with Glargine a while ago and rosiglitazone was associated with cardiovascular events in humans.
Patients with metabolic syndrome and insulin resistance form the main population of Type 2 diabetes where using DPP4 inhibitors with metformin is a major choice currently while it has no effect on body weight
After the rosiglitazone relationship to cardiovascular deaths pioglitazone is very minimally prescribed in primary care hence in terms of second line therapy the choice lies mostly towards a DPP4 inhibitor
Glucagon like peptide 1 analogues resulted in weight loss of 1.4 kg and 4.8 kg compared to placebo and insulin, though the cost price for prescribing exenatide annually in UK will be 820 pounds / year and liraglutide will be around 950 pounds / year compared to sitagliptin of around 400 pounds / year and metformin to 50 pounds/ year and hence cost effect proves inferior to the achieved goals in GLP 1 analogues

Competing interests: No competing interests

21 March 2012
Moienudeen Abdul Basith Khan
Family Physician
Hatton Medical Practice
186,Hatton Road , Bedfont , Middlesex , TW14 8JE