Erlich Deborah R, Slawson David C, Shaughnessy Allen
Tufts University, Boston, MA 02111, USA.
FP Essent. 2013 May;408:20-4.
Metformin is the first-line treatment for patients with diabetes because it reduces mortality rates. If metformin is contraindicated or is not tolerated, any one of the other available antihyperglycemic drugs may be used as monotherapy. These drugs are equally effective for glucose control, lowering A1c by approximately 1%. Evidence of their benefit for reducing mortality or morbidity, or improving health-related quality of life is lacking. A sulfonylurea, pioglitazone, or exenatide can be added to maximally dosed metformin if additional glycemic control is necessary. Sulfonylureas and pioglitazone often cause weight gain. The combination of metformin plus a sulfonylurea is associated with a greater risk of hypoglycemia and mortality than the combination of metformin and a thiazolidinedione (ie, glitazone). Thiazolidinediones are contraindicated in patients with severe heart failure or liver disease. Newer drug classes target incretin, the hormone that stimulates food-dependent insulin secretion. The incretin mimetic exenatide, a high-cost injectable drug, is similar to metformin for reduction of A1c and body mass index. Incretin-enhancing dipeptidyl-peptidase 4 inhibitors (ie, gliptins) are inferior to metformin for lowering A1c and body mass index; little is known about their effect on all-cause mortality. Fixed combination products might improve ease of use and adherence; they might also reduce cost and risk of adverse effects.
二甲双胍是糖尿病患者的一线治疗药物，因为它能降低死亡率。如果二甲双胍禁忌使用或不耐受，任何一种其他可用的抗高血糖药物都可作为单一疗法使用。这些药物在控制血糖方面同样有效，可使糖化血红蛋白（A1c）降低约1%。但缺乏它们在降低死亡率或发病率或改善健康相关生活质量方面的益处证据。如果需要进一步控制血糖，可在最大剂量的二甲双胍基础上加用磺脲类药物、吡格列酮或艾塞那肽。磺脲类药物和吡格列酮常导致体重增加。与二甲双胍和噻唑烷二酮类药物（即格列酮类）联合使用相比，二甲双胍与磺脲类药物联合使用会增加低血糖和死亡风险。噻唑烷二酮类药物在重度心力衰竭或肝病患者中禁用。新型药物类别作用于肠促胰岛素，即刺激依赖食物的胰岛素分泌的激素。肠促胰岛素类似物艾塞那肽是一种高成本的注射药物，在降低糖化血红蛋白和体重指数方面与二甲双胍相似。增强肠促胰岛素的二肽基肽酶4抑制剂（即格列汀类）在降低糖化血红蛋白和体重指数方面不如二甲双胍；对其对全因死亡率的影响了解甚少。固定复方制剂可能会提高用药便利性和依从性；它们还可能降低成本和不良反应风险。
