The n e w e ng l a n d j o u r na l of m e dic i n e

Cl inic a l Decisions
Interactive at nejm.org

Management of Type 2 Diabetes Polling Results

Joann M. Schulte, D.O., M.P.H., Carla S. Rothaus, M.D., and Jonathan N. Adler, M.D.

Diabetes is a common condition, and preventing
complications is a difficult clinical challenge.
Recently, we gave readers the opportunity to
share their opinions on effective management of
diabetes in Clinical Decisions, an interactive fea-
ture in which experts discuss a controversial
topic and readers vote and post comments. We
presented the case of Agnes, a 51-year-old widow
who has well-controlled hypertension and type 2
diabetes that requires better management.1 She
has maintained her weight, exercises three times
a week, and has been taking metformin. Never-
theless, her glycated hemoglobin level had risen
as high as 9.0%, and the most recent level was
8.0%. Assuming that an additional drug would
help Agnes improve the control of her diabetes,
including lowering her glycated hemoglobin level
to 7.0%, we asked readers to choose between
recommending a dipeptidyl peptidase 4 (DPP-4)
inhibitor (gliptin) or a sodium glucose cotrans-
porter 2 (SGLT2) inhibitor (gliflozin).
Although we note that this was not a scien-
tific poll, the results were informative. Our web-
site received votes from 1353 readers in 95 coun-
tries, and 144 readers posted comments. We
received the most votes from readers in the
United States (366 readers [27.1%]), followed by
readers in Mexico (96 [7.1%]), Brazil (84 [6.2%]),
and India (61 [4.5%]).
A large majority of readers voted to add a
gliptin rather than a gliflozin (978 readers
[72.3%] vs. 375 readers [27.7%]), and readers in
76 countries preferred that option. U.S. readers
from 43 states and the District of Columbia
voted, with 62.3% (218 of the 350 U.S. readers
who voted for one of the two options) recom-
mending the addition of a gliptin and 37.7%
(132 readers) recommending the addition of a
gliflozin. Most of the readers from Mexico who
voted preferred the addition of a gliptin over a
gliflozin (73 readers [76.0%] vs. 23 readers
[24.0%]). Among readers from Brazil, 76.2% (64
readers) preferred a gliptin, and 23.8% (20 read-
ers) preferred a gliflozin. Readers from India
also preferred a gliptin to a gliflozin (52 readers
[85.2%] vs. 9 readers [14.8%], respectively).
A dominant theme expressed in the 144 com-
ments was the imperative to provide education
regarding diet and exercise, regardless of wheth-
er another drug was added to Agness existing
regimen. Just under 20% of readers who com-
mented were opposed to adding a second drug
of any kind, preferring that Agnes make a re-
newed effort to lose weight (while acknowledg-
ing the time commitment that counseling on
nutrition and exercise requires from caregivers).
Other readers advocated drug options not of-
fered in this scenario, including insulin, sulfo-
nylureas, and glucagon-like peptide 1 (GLP-1)
agonists. Many readers commented that Agness
aversion to needles could be overcome with edu-
cation and support. Several commenters thought
that the focus on reducing Agness glycated he-
moglobin level was misplaced and distracted
from the need to modify her other risk factors
for cardiovascular disease. Many readers were
concerned about the safety profile of SGTL2 in-
hibitors, with some adding that these drugs are
not available in their country.
Managing diabetes so that patients will have
the best possible outcomes and the fewest com-
plications is complex, and providers who treat
patients with diabetes will continue to be chal-
lenged to provide excellent care.
1. Hirsch IB, Molitch ME. Clinical decisions: glycemic man-
agement in a patient with type 2 diabetes. N Engl J Med 2013;369:
1370-2.
DOI: 10.1056/NEJMclde1314028
Copyright 2014 Massachusetts Medical Society.

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