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

Sang Youl Rhee

doi:10.4093/jkd.2018.19.1.15

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

Focused Issue

J Korean Diabetes 2018;19(1):15-22.

Published online: 10 January 2018

DOI: https://doi.org/10.4093/jkd.2018.19.1.15

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

Sang Youl Rhee

On Behalf of the Committee of Clinical Practice Guideline of the Korean Diabetes Association

Department of Endocrinology and Metabolism, Kyung Hee University School of Medicine, Seoul, Korea

Corresponding author: Sang Youl Rhee Department of Endocrinology and Metabolism, Kyung Hee University School of Medicine, 23 Kyungheedae-ro, Dongdaemun-gu, Seoul 02447, Korea, E-mail: rheesy@khu.ac.kr

Received 28 December 2017 Accepted 24 January 2018

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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.

Keywords: Diabetes mellitus, type 2, Hypoglycemic agents, Metformin, Practice guideline

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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	Hypoglycemia^a	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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