The n e w e ng l a n d j o u r na l of m e dic i n e Cl inic a l Decisions Interactive at nejm.org Management of Type 2 Diabetes — Polling Results Joann M. Schulte, D.O., M.P.H., Carla S. Rothaus, M.D., and Jonathan N. Adler, M.D. Diabetes is a common condition, and preventing complications is a difficult clinical challenge. Recently, we gave readers the opportunity to share their opinions on effective management of diabetes in Clinical Decisions, an interactive feature in which experts discuss a controversial topic and readers vote and post comments. We presented the case of Agnes, a 51-year-old widow who has well-controlled hypertension and type 2 diabetes that requires better management.1 She has maintained her weight, exercises three times a week, and has been taking metformin. Nevertheless, her glycated hemoglobin level had risen as high as 9.0%, and the most recent level was 8.0%. Assuming that an additional drug would help Agnes improve the control of her diabetes, including lowering her glycated hemoglobin level to 7.0%, we asked readers to choose between recommending a dipeptidyl peptidase 4 (DPP-4) inhibitor (“gliptin”) or a sodium glucose cotransporter 2 (SGLT2) inhibitor (“gliflozin”). Although we note that this was not a scientific poll, the results were informative. Our website received votes from 1353 readers in 95 countries, and 144 readers posted comments. We received the most votes from readers in the United States (366 readers [27.1%]), followed by readers in Mexico (96 [7.1%]), Brazil (84 [6.2%]), and India (61 [4.5%]). A large majority of readers voted to add a gliptin rather than a gliflozin (978 readers [72.3%] vs. 375 readers [27.7%]), and readers in 76 countries preferred that option. U.S. readers from 43 states and the District of Columbia voted, with 62.3% (218 of the 350 U.S. readers who voted for one of the two options) recommending the addition of a gliptin and 37.7% (132 readers) recommending the addition of a gliflozin. Most of the readers from Mexico who voted preferred the addition of a gliptin over a n engl j med 370;1 gliflozin (73 readers [76.0%] vs. 23 readers [24.0%]). Among readers from Brazil, 76.2% (64 readers) preferred a gliptin, and 23.8% (20 readers) preferred a gliflozin. Readers from India also preferred a gliptin to a gliflozin (52 readers [85.2%] vs. 9 readers [14.8%], respectively). A dominant theme expressed in the 144 comments was the imperative to provide education regarding diet and exercise, regardless of whether another drug was added to Agnes’s existing regimen. Just under 20% of readers who commented were opposed to adding a second drug of any kind, preferring that Agnes make a renewed effort to lose weight (while acknowledging the time commitment that counseling on nutrition and exercise requires from caregivers). Other readers advocated drug options not offered in this scenario, including insulin, sulfonylureas, and glucagon-like peptide 1 (GLP-1) agonists. Many readers commented that Agnes’s aversion to needles could be overcome with education and support. Several commenters thought that the focus on reducing Agnes’s glycated hemoglobin level was misplaced and distracted from the need to modify her other risk factors for cardiovascular disease. Many readers were concerned about the safety profile of SGTL2 inhibitors, with some adding that these drugs are not available in their country. Managing diabetes so that patients will have the best possible outcomes and the fewest complications is complex, and providers who treat patients with diabetes will continue to be challenged to provide excellent care. 1. Hirsch IB, Molitch ME. Clinical decisions: glycemic man- agement in a patient with type 2 diabetes. N Engl J Med 2013;369: 1370-2. DOI: 10.1056/NEJMclde1314028 Copyright © 2014 Massachusetts Medical Society. nejm.org january 2, 2014 The New England Journal of Medicine Downloaded from nejm.org by HECTOR GARCIA on February 7, 2014. For personal use only. No other uses without permission. Copyright © 2014 Massachusetts Medical Society. All rights reserved. e2
