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What Should the Initial Medication Be for Type 2 Diabetes?

Acarbose is similar to metformin in efficacy in new study…. 

The alpha-glucosidase inhibitor acarbose has approval for treatment of type 2 diabetes as an adjunct to diet and lifestyle management. Both acarbose and metformin are widely used as treatments for type 2 diabetes, and acarbose is used extensively in China and other Asian countries. In contrast, metformin has been used primarily in white populations, and the results have been extrapolated to other populations. In this study, Yang and colleagues aimed to examine the relative efficacy of acarbose and metformin in Chinese patients with newly diagnosed type 2 diabetes.

The study took place over a period of 48 weeks in patients who were newly diagnosed with type 2 diabetes, with a mean HbA1c of 7.5%, fasting plasma glucose ≤200 mg/dL, and a body mass index of 19 to 30. Investigators at 11 sites in China enrolled patients ages 30 to 70, who met World Health Organization criteria for type 2 diabetes and who had not been treated with medication or had been treated for no more than a month. The primary endpoint was change in HbA1c from baseline to 48 weeks.

After a 4-week lifestyle modification run-in, patients were assigned to 24 weeks of monotherapy with metformin or acarbose as the initial treatment, followed by a 24-week therapy phase during which add-on therapy was used if prespecified glucose targets were not achieved. Of the 788 patients randomly assigned to treatment groups, 784 patients started the intended study drug. During follow-up, 16% of patients in the acarbose group and 20% in the metformin group discontinued treatment. After 24 weeks investigators added insulin secretagogues for patients with inadequate glycemic control; five patients in the acarbose arm and four in the metformin arm received the add-on therapy. HbA1c reduction at week 24 was −1.17% in the acarbose group and −1.19% in the metformin group. At week 48, the HbA1c reduction was −1.11% (acarbose) and −1.12% (metformin) with difference 0.01% (p=0.8999). Additionally, results did not differ by body weight, BMI, or percentage of carbohydrate in the diet. Six (2%) patients in the acarbose group and seven (2%) patients in the metformin group had serious adverse events, and two (1%) and four (1%) had hypoglycemic episodes.

According to the authors, this study is the first head-to-head comparison of metformin and acarbose as initial therapy for type 2 diabetes after failure of therapeutic lifestyle modification. Based on the results, the authors conclude that both acarbose and metformin are well tolerated and have similar efficacy as initial therapy for HbA1c reduction in patients with type 2 diabetes. However, they also noted the need for longer follow-up in patients treated with acarbose or with some of the newer hypoglycemic agents.

Practice Pearls: 
  • Both acarbose and metformin are well tolerated and have similar efficacy as initial therapy for HbA1c reduction.
  • Rates of serious adverse events and hypoglycemic episodes between the two drugs were equivalent.
  • Longer follow-up in patients treated with acarbose was needed in the study.

The Lancet Diabetes & Endocrinology, October 2013