From American College of Physicians and University of Pennsylvania Health System, Philadelphia, Pennsylvania; Massachusetts General Hospital, Boston, Massachusetts; and Oregon Health and Science University, Portland, Oregon.
Ann Intern Med. 2017 Feb 21;166(4):279-290. doi: 10.7326/M16-1860. Epub 2017 Jan 3.
The American College of Physicians (ACP) developed this guideline to present the evidence and provide clinical recommendations on oral pharmacologic treatment of type 2 diabetes in adults. This guideline serves as an update to the 2012 ACP guideline on the same topic. This guideline is endorsed by the American Academy of Family Physicians.
This guideline is based on a systematic review of randomized, controlled trials and observational studies published through December 2015 on the comparative effectiveness of oral medications for type 2 diabetes. Evaluated interventions included metformin, thiazolidinediones, sulfonylureas, dipeptidyl peptidase-4 (DPP-4) inhibitors, and sodium-glucose cotransporter-2 (SGLT-2) inhibitors. Study quality was assessed, data were extracted, and results were summarized qualitatively on the basis of the totality of evidence identified by using several databases. Evaluated outcomes included intermediate outcomes of hemoglobin A1c, weight, systolic blood pressure, and heart rate; all-cause mortality; cardiovascular and cerebrovascular morbidity and mortality; retinopathy, nephropathy, and neuropathy; and harms. This guideline grades the recommendations by using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system.
The target audience for this guideline includes all clinicians, and the target patient population includes adults with type 2 diabetes.
RECOMMENDATION 1: ACP recommends that clinicians prescribe metformin to patients with type 2 diabetes when pharmacologic therapy is needed to improve glycemic control. (Grade: strong recommendation; moderate-quality evidence).
RECOMMENDATION 2: ACP recommends that clinicians consider adding either a sulfonylurea, a thiazolidinedione, an SGLT-2 inhibitor, or a DPP-4 inhibitor to metformin to improve glycemic control when a second oral therapy is considered. (Grade: weak recommendation; moderate-quality evidence.) ACP recommends that clinicians and patients select among medications after discussing benefits, adverse effects, and costs.
美国医师学院（ACP）制定了本指南，旨在呈现关于成人 2 型糖尿病口服药物治疗的证据并提供临床建议。本指南是对 2012 年 ACP 关于同一主题指南的更新。本指南得到了美国家庭医师学会的认可。
本指南基于对截至 2015 年 12 月有关 2 型糖尿病口服药物比较疗效的随机对照试验和观察性研究的系统评价。评估的干预措施包括二甲双胍、噻唑烷二酮类、磺酰脲类、二肽基肽酶-4（DPP-4）抑制剂和钠-葡萄糖协同转运蛋白-2（SGLT-2）抑制剂。评估了研究质量、提取数据，并根据使用多个数据库确定的证据总量，定性总结结果。评估的结果包括血红蛋白 A1c、体重、收缩压和心率的中间结果；全因死亡率；心血管和脑血管发病率和死亡率；视网膜病变、肾病和神经病变；以及危害。本指南使用 GRADE（推荐评估、制定与评价）系统对建议进行分级。
本指南的目标受众包括所有临床医生，目标患者人群包括需要药物治疗来改善血糖控制的 2 型糖尿病患者。
建议 1：ACP 建议当需要药物治疗来改善血糖控制时，临床医生应为 2 型糖尿病患者开具二甲双胍。（强烈推荐；中等质量证据）
建议 2：ACP 建议当考虑使用第二种口服药物治疗时，临床医生应考虑在二甲双胍的基础上添加磺酰脲类、噻唑烷二酮类、SGLT-2 抑制剂或 DPP-4 抑制剂以改善血糖控制。（弱推荐；中等质量证据）ACP 建议临床医生和患者在讨论了益处、不良反应和成本后，在药物之间进行选择。
