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The role of co-morbidity in the selection of antidiabetic pharmacotherapy in type-2 diabetes

Diethelm Tschöpe1*, Markolf Hanefeld2, Juris J Meier3, Anselm K Gitt4, Martin Halle56, Peter Bramlage7 and Petra-Maria Schumm-Draeger8

Author Affiliations

1 Herz- und Diabeteszentrum Nordrhein-Westfalen in Bad Oeynhausen, Universitätsklinik der Ruhr Universität, Bochum, Germany

2 Centre for Clinical Studies Professor Hanefeld, Dresden, Germany

3 Department of Medicine I, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany

4 Institut für Herzinfarktforschung Ludwigshafen, Ludwigshafen, Germany

5 Zentrum für Prävention und Sportmedizin an der TU München, Munchen, Germany

6 German Centre for Cardiovascular Research (DZHK), partner site Munich Heart Alliance, Munich, Germany

7 Institut für Pharmakologie und präventive Medizin, Mahlow, Germany

8 Med. Klinik 3, Endokrinologie, Diabetologie und Angiologie, Klinikum München-Bogenhausen, München, Germany

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Cardiovascular Diabetology 2013, 12:62  doi:10.1186/1475-2840-12-62

Published: 10 April 2013


Metformin is, if not contraindicated and if tolerated, usually preferred over other antidiabetic drugs for the first line treatment of type-2 diabetes. The particular decision on which antidiabetic agent to use is based on variables such as efficacy, cost, potential side effects, effects on weight, comorbidities, hypoglycemia, risk, and patient preferences. However, there is no guidance how to consider these in the selection of antidiabetic drug treatment. In this work, we aimed to summarize available evidence and tried to give pragmatic treatment recommendations from a clinical practice perspective.

There are clear contraindications for some drugs in those with impaired renal and liver function and precautions in those with heart failure for the use of metformin (NYHA III-IV) and glitazones. On the other hand, GLP-1 analogs, DPP-4 inhibitors and acarbose are generally less critical and can be used in the majority of patients. We identified the following gaps with respect to the selection of antidiabetic drug treatment in patients with co-morbid disease conditions: 1) Guidelines fail to give advice on the use of specific antidiabetic drugs in patients with co-morbidity. 2) The literature is deficient in studies documenting antidiabetic drug use in patients with severely impaired renal function, diabetic retinopathy, cerebrovascular disease and systolic heart failure. 3) Further there are no specific data on patients with multiple of these co-morbid disease conditions. We postulate that differential use of antidiabetic drugs in patients with co-morbid disease constellations will help to reduce treatment related complications and might improve prognosis.