Therapy of Type 2 diabetes: more gliflozines and less metformin?

Abstract

Metformin is a frequently used anti-diabetic drug. In addition to the well-known modulating properties on glyco-metabolic control, metformin reduces cardiovascular (CV) risk partly independently of its anti-hyperglycaemic effect. The use of ‘new’ anti-diabetic drugs, inhibitors of the renal Na-glucose co-transporter (SGLTs-I or ‘gliflozines’) and GLP-1 receptor agonists (GLP1-RAs), has further contributed to challenge the strictly ‘gluco-centric’ view of diabetic CV disease. Several controlled trials have demonstrated that the cardio-renal benefits of gliflozines and GLP1-RAs are present regardless of the presence of metformin as ‘background’ therapy. The impact on the ‘cardio-renal continuum’ exerted by SGLTs-I was also noted in non-diabetic patients with heart failure and reduced or preserved ventricular function and different levels of renal function. These drugs reduced re-hospitalization, CV mortality, and progression to end-stage renal disease. These clinical acquisitions, implemented by Scientific Societies, have led to a change in the therapeutic approach to diabetic cardio-renal disease. Although metformin still represents a valid therapeutic option to be offered particularly to ‘naïve’ diabetic patients without previous cardio-renal events, SGLTs-I and/or GLP1-RAs emerge as ‘first-line’ drugs in diabetic patients with previous CV events, or at high CV risk, without having to request ‘on board’ metformin therapy.

Diagnosis rates, therapeutic characteristics, lifestyle, and cancer screening habits of patients with diabetes mellitus in a highly deprived region in Hungary: a cross-sectional analysis

“…Since undiagnosed diabetes is associated with worse disease outcomes ( 21 , 22 ), socially deprived populations should be targeted with diabetes screening programs to increase early recognition of diabetes and initiate therapy and lifestyle modification. Metformin is often considered as the first choice medication for the treatment of most diabetes cases ( 23 ). In our study, we found that metformin was prescribed in 75.8% of the cases, which is above the national average of 66% ( 24 ), but still somewhat lower than in other European countries, where metformin prescription rates may reach 83% ( 25 ).…”

Effects of SGLT2 Inhibitors with and without Metformin in High-Risk, Treatment-Naïve Patients with Diabetes

“…Metformin (dimethylbiguanide), a biguanide anti-diabetic agent, has been commonly used and recommended as the first-line treatment in T2DM. Metformin modulates the glycometabolic control by activating the enzyme AMPK (AMP-activated protein kinase) in hepatocytes and skeletal muscle, thereby increasing glucose uptake and reducing gluconeogenesis and hepatic glycogenolysis [ 27 ]. It has also been administered for inducing ovulatory menstrual cycles in oligo-amenorrhoeic patients with polycystic ovary syndrome [ 28 ].…”