Counterpoint: A Diabetes Outcome Progression Trial (ADOPT): Good for Sulfonylureas?
- Ebaa Al-Ozairi, MD,
- Latika Sibal, MD and
- Philip Home, MA, DM, DPHIL
- From the Newcastle Diabetes Centre and Newcastle University, Newcastle upon Tyne, U.K
- Address correspondence and reprint requests to Prof. Philip Home, SCMS-Diabetes, The Medical School, Framlington Place, Newcastle upon Tyne, NE2 4HH, U.K. E-mail: philip.home{at}ncl.ac.uk
A Diabetes Outcome Progression Trial (ADOPT) was conceived in the hope that the seemingly inexorable decline in islet B-cell function described with metformin, sulfonylureas, and insulin in the UK Prospective Diabetes Study (UKPDS) might be stopped or inhibited to a major degree by peroxisome proliferator–activated receptor-γ agonists, in particular rosiglitazone (1,2). It was already well recognized that the rapid early efficacy of sulfonylureas in lowering glucose was not retained to 12 months, and that metformin and thiazolidinediones had slow onset of action over months, so the design of the study necessarily had to enable decline of measures of blood glucose control to be assessed for a considerable period from 1 year onwards. However, the extent (degree and time) to which this early efficacy of the sulfonylureas in protecting against hyperglycemia would persist was not accurately known. The study also provided a good opportunity to compare durability of effect of the three classes of drugs directly in the context of some shorter-term studies since published (3).
Metformin is currently well established as first-line therapy in people with type 2 diabetes, usually after lifestyle measures fail to achieve A1C levels <6.5%, although some consensus (as opposed to evidence-based) guidelines have suggested initiation immediately from diagnosis (4,5). This review will not challenge those ideas, although the evidence is not as strong as sometimes assumed. The exceptions to first-line metformin use are where metformin is contraindicated, perhaps where someone is not overweight, and where presentation glucose levels are high and the rapid effect of a sulfonylurea is needed. In situations where metformin is contraindicated, or as second-line add-on therapy to metformin when target levels are no longer met, the alternative choice to a sulfonylurea would be a thiazolidinedione or possibly a gliptin (it is assumed insulin would not usually …
