Acarbose vs metformin for new-onset type 2 diabetes

Abstract

Wenying Yang and colleagues (October 18) report the fi ndings of a randomised controlled trial comparing acarbose with metformin as initial therapy for Chinese patients with newly diagnosed type 2 diabetes, showing similar tolerability and effi cacy. In addition to being the fi rst head-to-head comparison of metformin and acarbose as fi rst-line therapy for type 2 diabetes after failure of therapeutic lifestyle modifi cation, this intervention study is interesting as it is relevant to individualisation of pharmacological antidiabetic treatment in Asian adults with type 2 diabetes. Interest in personalised diabetes treatment is increasing. Personalised therapy involves an approach to clinical decisions that is applied to each individual patient and has, as a prerequisite, an accurate characterisation of that patient (phenotyping). Personalised therapy involves applying knowledge, scientifi c evidence, and common sense, and taking the realities of each individual patient’s circumstances into account. The fi nal aim is to optimise treatment responses, whilst similtaneously improving tolerability and compliance. To apply this in practice, physicians feel more comfortable having pragmatic aids such as predefi ned algorithms. Since 2010, the Italian Association of Diabetologists (Associazione Medici Diabetologi) has recognised the need to develop personalised treatment plans for patients with type 2 diabetes, taking into account the patient’s individual pattern of hyperglycaemia (phenotype), with the safest possible glycaemic control as a goal. Accordingly, tailored therapeutic algorithms have been developed for some of the most common type 2 diabetes phenotypes. These algorithms are available online in English, as a browser-operated interactive instrument. On the basis of a patient’s clinical features, the user can access a step-by-step suggested additive therapeutic approach. In fi ve of six Associazione Medici Diabetologi algorithms, alfa-glucosidase inhibitors are already considered as a fi rst pharmacological option for patients who are intolerant or have contraindications to metformin and who have predominantly postprandial hyperglycaemia. The study by Yang and colleagues shows that eastern Asian patients with newly diagnosed type 2 diabetes, a low BMI, a high dietary carbohydrate intake, and exaggerated postprandial glucose excursion can appropriately be treated with an alfa-glucosidase inhibitor as an alternative to metformin, at least in the short term, although cardiovascular eff ects of acarbose have yet to be investigated fully. This study, in our opinion, represents a creditable contribution and a step forward towards the development of population-specifi c and patho physiology-based treatment algorithms for type 2 diabetes.