Abdul-Ghani Muhammad, DeFronzo Ralph A
Division of Diabetes, University of Texas Health Science Center at San Antonio, San Antonio, TX
Diabetes Research, Academic Health System, Hamad General Hospital, Doha, Qatar.
Diabetes Care. 2017 Aug;40(8):1121-1127. doi: 10.2337/dc16-2368.
Most treatment guidelines, including those from the American Diabetes Association/European Association for the Study of Diabetes and the International Diabetes Federation, suggest metformin be used as the first-line therapy after diet and exercise. This recommendation is based on the considerable body of evidence that has accumulated over the last 30 years, but it is also supported on clinical grounds based on metformin's affordability and tolerability. As such, metformin is the most commonly used oral antihyperglycemic agent in the U.S. However, based on the release of newer agents over the recent past, some have suggested that the modern approach to disease management should be based upon identification of its etiology and correcting the underlying biological disturbances. That is, we should use interventions that normalize or at least ameliorate the recognized derangements in physiology that drive the clinical manifestation of disease, in this circumstance, hyperglycemia. Thus, it is argued that therapeutic interventions that target glycemia but do not correct the underlying pathogenic disturbances are unlikely to result in a sustained benefit on the disease process. In our field, there is an evolving debate regarding the suggested first step in diabetes management and a call for a new paradigm. Given the current controversy, we provide a Point-Counterpoint debate on this issue. In the point narrative below that precedes the counterpoint narrative, Drs. Abdul-Ghani and DeFronzo provide their argument that a treatment approach for type 2 diabetes based upon correcting the underlying pathophysiological abnormalities responsible for the development of hyperglycemia provides the best therapeutic strategy. Such an approach requires a change in the recommendation for first-line therapy from metformin to a GLP-1 receptor agonist. In the counterpoint narrative that follows Drs. Abdul-Ghani and DeFronzo's contribution, Dr. Inzucchi argues that, based on the medical community's extensive experience and the drug's demonstrated efficacy, safety, low cost, and cardiovascular benefits, metformin should remain the "foundation therapy" for all patients with type 2 diabetes, barring contraindications.-William T. CefaluChief Scientific, Medical & Mission Officer, American Diabetes Association.
大多数治疗指南，包括美国糖尿病协会/欧洲糖尿病研究协会以及国际糖尿病联合会发布的指南，均建议二甲双胍在饮食和运动之后用作一线治疗药物。这一推荐基于过去30年积累的大量证据，同时也基于二甲双胍的可承受性和耐受性等临床依据。因此，二甲双胍是美国最常用的口服降糖药。然而，鉴于最近新型药物的问世，一些人认为现代疾病管理方法应基于病因识别并纠正潜在的生物学紊乱。也就是说，我们应采用能使驱动疾病临床表现（在这种情况下即高血糖症）的生理紊乱正常化或至少改善的干预措施。因此，有人认为针对血糖水平但未纠正潜在致病紊乱的治疗干预不太可能给疾病进程带来持续益处。在我们这个领域，关于糖尿病管理的第一步建议存在着不断演变的争论，并且有人呼吁采用新的范例。鉴于当前的争议，我们针对此问题进行了一场正方与反方的辩论。在反方叙述之前的正方叙述中，阿卜杜勒 - 加尼博士和德弗龙佐博士提出他们的观点，即基于纠正导致高血糖症发生的潜在病理生理异常的2型糖尿病治疗方法提供了最佳治疗策略。这样一种方法需要将一线治疗的推荐从二甲双胍改为胰高血糖素样肽 - 1（GLP - 1）受体激动剂。在阿卜杜勒 - 加尼博士和德弗龙佐博士的观点之后的反方叙述中，因祖基博士认为，基于医学界的广泛经验以及该药物已证实的疗效、安全性、低成本和心血管益处，除非有禁忌证，二甲双胍应仍然是所有2型糖尿病患者的“基础治疗药物”。
美国糖尿病协会首席科学、医学与使命官
