CAVEATS
Did unmeasured confounders play a role?
Unmeasured confounders potentially bias all observational population cohort results. In this particular study, there may have been unmeasured but significant patient factors that providers used to choose diabetes medications. Also, the study did not evaluate diabetes control, although previous studies have shown similar glucose control between sulfonylureas and DPP-4 inhibitors when added to metformin.6
Another caveat is that the results from this study group may not be generalizable to other populations due to physiologic differences. People of Asian ancestry are at risk for T2DM at a lower BMI than people of European ancestry, which could affect the outcomes of interest.9
Furthermore, the study did not evaluate outcomes based on whether patients were taking first-, second-, or third-generation sulfonylureas. Some sulfonylureas (eg, glyburide) carry a higher risk for hypoglycemia, which could bias the results.10
Lastly, the study only provides guidance when choosing between a sulfonylurea and a DPP-4 inhibitor for secondline pharmacotherapy. The GRADE trial, due to be completed in 2023, is comparing sulfonylureas, DPP-4 inhibitors, GLP-1 agonists, and insulin as add-on medications to metformin; it may provide more data on which to base treatment decisions.11
CHALLENGES TO IMPLEMENTATION
DPP-4s are more expensive
Sulfonylureas and DPP-4 inhibitors are both available as generic medications, but the cost of DPP-4 inhibitors remains significantly higher.12 Higher copays and deductibles could affect patient preference. For patients without health insurance, sulfonylureas are available on the discounted drug lists of many major retailers, while DPP-4 inhibitors are not.
ACKNOWLEDGEMENT
The PURLs Surveillance System was supported in part by Grant Number UL1RR024999 from the National Center For Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center For Research Resources or the National Institutes of Health.
Copyright © 2017. The Family Physicians Inquiries Network. All rights reserved.
Reprinted with permission from the Family Physicians Inquiries Network and The Journal of Family Practice. 2017;66(1):42-44.