Newscast: Lead Story - Comparison of Oral Medications for Type 2 Diabetes
Rand: This is Healthcare 411 for the week of August 8, 2007.
Nicole: Healthcare 411 is produced by AHRQ, the Agency for Healthcare Research and Quality, part of the U.S. Department of Health and Human Services. I’m Nicole Lacroix.
Rand: And I’m Rand Gardner.
Nicole: Coming up:
Rand: In News and Numbers, the number of orthopedic procedures increased dramatically in seven years.
Nicole: And a new review compares oral medications for type 2 diabetes. More after this.
[Begin PSA: Be an Active Member of Your Health Care Team]
Narrator: Former Olympic skater, now orthopedic surgeon, Dr. Debi Thomas.
Debi Thomas: Learning a sport can take time, determination and training. The same thing is also true of a healthy life style. Eat right. Exercise. And Don’t smoke. Be an active member of your health care team. Together you can fight diseases like diabetes, high blood pressure and osteoporosis. Start training today for a healthier life. Be Active in your health care!
Narrator: For more information go to www.ahrq.gov. A message from the U.S. Agency for Healthcare Research and Quality.
Nicole: First, the numbers.
Nicole: Orthopedic procedures increased by nearly 25 percent between 1997 and 2005, climbing from about 822,000 procedures to 1.3 million. This was driven by a 32 percent increase in total and partial hip replacement, a 69 percent rise in knee reconstruction or replacement, and a 73 percent increase in spinal fusion operations. Hospitals spent $31.5 billion on orthopedic-related care in 2005. Medicare paid the largest share of hospital costs for knee surgery and hip replacements. Private insurance paid for more than half of spinal fusions, which were more likely to be performed on people under 65. These data are from AHRQ’s Healthcare Cost and Utilization Project.
Rand: If you’re one of about 16 million Americans with type 2 diabetes, a landmark review may help you and your doctor decide which oral medication is right for you. The study is the first to summarize evidence on the effectiveness of and adverse events from approved oral medications for type 2 diabetes commonly used in the United States. AHRQ’s Effective Health Care program at the Johns Hopkins University Evidence-based Practice Center in Baltimore conducted research that showed while most diabetes drugs do a similar job of controlling blood sugar; some medications have added benefits like reduced risk of weight gain. Still some other medications may have dangerous side effects. Joining us now to talk about the findings is one of the researchers who led the review, Dr. Shari Bolen, an instructor with the Division of General Internal Medicine at Johns Hopkins University. Welcome, Dr. Bolen.
Dr. Bolen: Thanks for having me.
Rand: First, could you explain the difference between type 1 and type 2 diabetes?
Dr. Bolen: Type 1 Diabetes occurs when the body doesn’t produce any insulin to help control blood sugar, and that can happen as a result of a virus or potentially an autoimmune disorder, and that’s where the body attacks its own organs, in this case the pancreas, so it doesn’t really work to secrete insulin. And this generally happens for children rather than adults, and requires people to be treated with regular insulin injections.
Rand: So what does your study tell us about the oral medications for type 2 diabetes?
Dr. Bolen: We typically monitor blood sugar for our type 2 diabetic patients with a hemoglobin A1c, and this is a measure of blood sugar control over the past three months. And in our review, that’s the main measure for blood sugar that we looked at, so the hemoglobin A1c, and we saw that almost all the medications offer about a 1 point absolute reduction in your hemoglobin A1c, and that combining diabetes medications actually works synergistically or together to actually reduce your hemoglobin A1c even further.
Rand: Dr. Bolen, could you explain what it means to achieve this 1 percent reduction?
Dr. Bolen: Sure. So a normal hemoglobin A1c in someone without diabetes is typically around 5 percent. In patients with diabetes, we like to see the hemoglobin A1c around 6.5 to 7 percent and that’s because we know that there’s an association with that hemoglobin A1c being high and then complications with diabetes, such as heart attack and risk of other complications like blindness. Therefore, a 1 percent absolute reduction in hemoglobin A1c might be going from something like 8 percent to 7 percent, which is generally a good improvement
Rand: Besides blood sugar, what are some of the other effects of diabetes drugs that you found?
Dr. Bolen: Well, we also looked at intermediate effects of the medications. For instance, we might look at cholesterol which is known to effect risk of heart attacks and risk of death, and so since there’s been some suggestion of association between the oral diabetes medications and cholesterol effects, we wanted to look at that as well. So we evaluated cholesterol and we also looked at weight gains, and weight, in and of itself, can be associated with other risk factors for heart disease and death. So in terms of weight, we found that metformin and acarbose were less likely to cause weight gain, while most of the other drugs were shown to increase weight. And they increase weight, on average, from two to eleven pounds, and the other medications seem to consistently increase a similar amount. And then for cholesterol, in particular, we noticed that metformin consistently decreased what’s considered bad cholesterol, and increased in patients taking some of the newer medications, such as rosiglitazone and pioglitazone. And pioglitzaone and rosiglitazone also cause a small, but significant, increase in good cholesterol.
Rand: Did the AHRQ review find anything with regard to oral diabetes drugs and risk for the heart?
Dr. Bolen: Yes, so we found that the older diabetes drugs appeared to have less risk of cardiovascular problems than some of the newer drugs, specifically the thiazolidinediones in the risk of congestive heart failure, and also, that these older drugs have the benefit of being less expensive than the newer drugs. Patients with a history of heart problems should know that these newer drugs, the thiazolidinediones, may actually cause a greater risk of congestive heart failure, and these include the pioglitazone, which is sold as Actos, and rosiglitazone, which is sold as Avandia. These were both found to be associated with a small absolute increase in congestive heart failure, meaning about 1 to 3 people in 100 people will have this sort of side effect, and this could be a little bit higher in people with a history of heart problems. Currently, there’s been a lot of controversy about whether Avandia, or rosiglitazone, may be associated with a small increase risk of heart attack. That question is still being investigated, and in our review, we found that the current evidence just isn’t strong enough to make any sort of firm conclusion. There is an FDA advisory panel that just recommended a stricter warning label for Avandia, or rosiglitazone, but they didn’t suggest pulling it off the market. And, also, it’s important to note that Actos, or pioglitazone, in the same class of medications, but a different medication, does not appear to have that same heart attack risk.
Rand: What else did you find about any other important effects of the oral meds?
Dr. Bolen: We found that certain drugs can cause low blood sugar, and if your blood sugar goes too low, that’s actually called hypoglycemia. In this case, second generation sulfonylureas, one of the older medications, and repaglinide, which is one of the newer medications, were both associated with more serious hypoglycemia than the other oral diabetes medications, and there has been one or two studies that suggest repaglinide may have less serious hypoglycemia if you’re older - over sixty-five or in people who skip meals, but I think this still needs further investigation before we know for sure because there’s only been one or two small studies. We also found that patients had noted gastrointestinal problems, such as diarrhea with metformin and acarbose. And that people who use metformin alone were more likely to experience diarrhea than if they took the metformin at a lower dose in combination with one of the other diabetes drugs. But, overall, we found that metformin had less risk of serious adverse events than the second generation sulfonylureas, or the thiazolidinediones.
Rand: Dr. Bolen, what else would you want people to know about diabetes?
Dr. Bolen: In 1980, type 2 diabetes was in 5 million Americans, and now in 2005, a couple years ago, it was up to 16 million and continues to increase. The general complications that we mentioned very briefly earlier, but just to reiterate, are, you know, problems with the heart, so if the blood sugar is high for long periods of time, then you might be at risk of heart attack, which may eventually lead to death. You’re at risk of blindness, which is a very severe complication, and also risk to damage to your kidneys or have nerve problems in your legs, or other parts of your body, as well as having risk of amputation to your legs or arms if they get infected. So that’s why it’s critical that people with diabetes have regular blood tests to make sure that their blood sugar is under control, along with having regular appointments with their doctors so that they can get their feet and eyes examined on a regular basis
Rand: Any final advice?
Dr. Bolen: While there are a number of excellent drugs to treat type 2 diabetes, it will be very important for you to discuss with your physician which one will be right for you. Finally, it’s extremely important to discuss with your doctor how to make eating right, exercise, and weight loss part of your overall treatment plan.
Rand: Dr. Shari Bolen, thank you so much for joining us today.
Dr. Bolen: Sure it’s my pleasure.
Rand: Dr. Bolen led a review that compared oral medications to treat diabetes. For a copy of the report, go to effectivehealthcare.ahrq.gov.
Nicole: That’s it for this week. For more information on these and other health-related stories and topics go to www.ahrq.gov. Healthcare 411 is produced by AHRQ, the Agency for Healthcare Research and Quality, part of the U.S. Department of Health and Human Services. For Rand Gardner, I’m Nicole Lacroix. Please join us for the next edition of Healthcare 411.