Journal List > J Korean Diabetes > v.19(1) > 1055093

Rhee: Monotherapy in Type 2 Diabetes Mellitus Patients 2017: A Position Statement of the Korean Diabetes Association

Abstract

When starting initial medication in people with type 2 diabetes mellitus (T2DM), the appropriate drug should be selected considering characteristics of the patient, efficacy, side effects, and cost. It is generally recommended to use metformin as the first-line treatment oral hypoglycemic agent in T2DM patients. Metformin is recommended as the first treatment because of its excellent glucose lowering effect, relatively mild side effects, long-term safety, low risk of hypoglycemia, and small weight gain. If it is difficult to use metformin as a first-line treatment, appropriate drugs can be selected based on the clinical situation.

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Table 1.
Oral antihyperglycemic agents for patients with type 2 diabetes mellitus used in Korea
Mechanism and common use Weight gain Hypoglycemiaa HbA1c reduction (%)a Side effects Caution
Biguanide (metformin) ↓ Hepatic glucose production Start with lower dose and titrate upward slowly Neutral or decrease No 1.0∼2.0 GI side effects (anorexia, nausea, vomiting, diarrhea, cramping), vitamin B12 deficiency, lactic acidosis (rare) Contraindication in severe hepatic or renal insufficiency (eGFR < 30 mL/min/1.73 m2), severe infection, dehydration, heart failure. Major operation or iodine-contrast use within 48 hours
Sulfonylurea (gliclazide, glipizide, glimepiride, glibenclamide) ↑ Insulin secretion from β-cells Before meal Yes Yes 1.0∼2.0   Severe hepatic or renal insufficiency, secondary failure
Meglitinide (repaglinide, nateglinide, mitiglinide) ↑ Insulin secretion from β-cells, ↓ postprandial hyperglycemia Before each meal Yes Yes 0.5∼1.5   Severe hepatic or renal insufficiency
DPP-4 inhibitor (sitagliptin, vildagliptin, saxagliptin, linagliptin, gemigliptin, alogliptin, teneligliptin, anagliptin) ↑ Postprandial incretin (GLP-1, GIP), ↑ glucose-dependent insulin secretion, ↓ postprandial glucagon secretion, ↓ postprandial hyperglycemia, use regardless of mealtime No No 0.5∼1.0 Angioedema, urticaria Acute pancreatitis Risk for heart failure (saxagliptin, alogliptin) Dose titration in severe hepatic or renal insufficiency
Thiazolidinedione (pioglitazone, lobeglitazone) ↑ Insulin sensitivity (muscle, adipose tissue), ↓ hepatic glucose production, once daily regardless of mealtime Yes No 0.5∼1.4 Edema, anemia, bone fracture, heart failure Heart failure, severe hepatic or renal insufficiency
SGLT-2 inhibitor (dapagliflozin, ipragliflozin, empagliflozin) ↓ Renal glucose reabsorption, ↑ glucosuria Once daily regardless of mealtime No No 0.5∼1.0 Genitourinary tract infections, polyuria, dehydration, DKA Old age, heart failure, hypotension, diuretics use, not for severe CKD (eGFR < 60 mL/min/1.73 m2)
α-glucosidase Inhibitor (acarbose, voglibose) ↓ Upper intestinal glucose absorption, ↓ postprandial hyperglycemia Before each meal No No 0.5∼1.0 GI side effects (flatulence, diarrhea, bloating) Severe hepatic or renal insufficiency, chronic inflammatory bowel disease with malabsorption, severe infection

Adapted from the article of Ko et al. Diabetes Metab J 2017;41:337–48 [1].

HbA1c, glycosylated hemoglobin; GI, gastrointestinal; eGFR, estimated glomerular filtration rate; DPP-4, dipeptidyl peptidase-4; GLP-1, glucagon-like peptide 1; GIP, gastric inhibitory polypeptide; SGLT2, sodium-glucose cotransporter 2; CKD, chronic kidney disease; DKA, diabetic ketoacidosis.

a Monotherapy.

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