Diabetes drugs compared - consumer reports health

The Oral Diabetes Drugs
Treating Type 2 Diabetes
Comparing Effectiveness, Safety, and Price
Six classes of oral medicines (and 12 individual drugs) are now available to help the 25.8 million people in theU.S. with type 2 diabetes control their blood sugar when diet and lifestyle changes are not enough. Our eval-uation of these medicines found the following: Newer drugs are no better. Two drugs from a class called the sulfonylureas and a drug named metformin havebeen around for more than a decade and work just as well as newer medicines. Indeed, several of the newerdrugs, such as Januvia and Onglyza, are less effective than the older ones. Newer drugs are no safer. All diabetes pills have the potential to cause adverse effects, both minor and serious.
The drugs' safety and side effect "profiles" may be the most important factor in your choice.
The newer drugs are more expensive. The newer diabetes medicines cost many times more than the older ones.
Taking more than one diabetes drug is often necessary. Many people with diabetes do not get enough blood sugarcontrol from one medicine. Two or more may be necessary. However, taking more than one diabetes drug raisesthe risk of adverse effects and increases costs.
Taking effectiveness, safety, adverse effects, dosing, and cost into consideration, we have chosen the followingas Consumer Reports Health Best Buy Drugs if your doctor and you have decided that you need medicine tocontrol your diabetes: Metformin and Metformin Sustained Release — alone or with glipizide or glimepiride Glipizide and Glipizide Sustained Release — alone or with metformin Glimepiride — alone or with metformin These medicines are available as low-cost generics, costing from $4 to $43 a month. If you have been diagnosedwith diabetes, we recommend that you try metformin first unless your health status prevents it.
If metformin fails to bring your blood sugar into normal range, we recommend you add glipizide or glimepiride.
This report was updated in June 2011. 2 • Consumer Reports Health Best Buy Drugs • The Oral Diabetes Drugs: Treating Type 2 Diabetes This report compares the effectiveness, safety, and cost of medicinesused to treat type 2 diabetes. It is part of a Consumer Reports projectto help you find safe, effective medicines that give you the most valuefor your health-care dollar. To learn more about the project and otherdrugs we've evaluated for other diseases and conditions, go toConsumerReportsHealth.org/BestBuyDrugs.
Type 2 diabetes is one of the most serious medical conditions affectingour nation today. The number of people who have it has been risingalarmingly. Type 2 diabetes used to be referred to as "adult onset" diabetes, but nolonger. In recent years, the incidence among children and adolescentshas exploded. Much of that surge is due to the dramatic increase in thelast 20 years in the number of young people who are physically inac-tive and overweight or obese.
The statistics are sobering. An estimated 25.8 million people in theU.S., or about 8 percent of the population, have diabetes. That's upfrom 2.5 percent of the population in 1980. Despite the increase of thedisease among the young, older people are still the largest age groupaffected with nearly 11 million people 65 or older afflicted with dia-betes. And about 1.9 million people are newly diagnosed with type 2diabetes every year. But despite widespread attention to the diabetes epidemic, about onein three people who have diabetes — some 7 million people — have notbeen diagnosed and do not know they have it. And many of thosewho have been diagnosed are not getting adequate treatment. A quar-ter to a third of the people who have been diagnosed with diabetes failto receive the medical care and medicines that research has shown tobe effective. Why is diabetes of such concern? Studies conclusively show that diabetesmore than doubles the risk of developing and dying of heart disease andother problems. Indeed, the condition is as potent a predictor and risk fac-tor for heart disease and heart attack as are cigarette smoking, high bloodpressure, and high cholesterol. In 2004, the latest year for which data isavailable, heart disease was a factor listed on 68 percent of diabetes-relat-ed death certificates among people 65 or older.
Diabetes also significantly raises the risk of a host of other problems.
These include: stroke, nerve damage, kidney damage; damage to theeye as well as total blindness; impotence, poor wound healing, andsusceptibility to infections that can fester and require amputations oftoes, feet, or part of a leg. The Oral Diabetes Drugs: Treating Type 2 Diabetes • Consumer Reports Health Best Buy Drugs • 3 In addition, people with diabetes are very likely to have other dangeroushealth conditions. One study found that 47 percent of people with dia-betes had two other heart disease risk factors (such as smoking, highblood pressure and high cholesterol) and 18 percent had three or more. Overall, diabetes is the seventh leading cause of death in the UnitedStates. It is also a leading cause of disability. At greatest risk of prema-ture disability and death are women (of all ethnic backgrounds),African Americans, Hispanics, American Indians, and the indigenouspeople of Alaska. Women have the same prevalence of diabetes as men, but recent stud-ies indicate women are much more likely to die from it. Minoritygroup members are both more prone to develop diabetes (due togenetic and environmental factors) and to become disabled or diefrom it (due to multiple factors, including that they are less likely toget good care). But proper treatment can keep people with diabetes healthy. In fact, allpeople with diabetes who receive proper and consistent care live goodquality lives, and can work and function normally.
Type 1 and type 2 diabetes — the difference
There is widespread misunderstanding about diabetes. This sectionexplains what the disease is and the difference between type 1 andtype 2. Diabetes is a disease characterized by elevation of blood glucose (asugar) caused by decreased production of the hormone insulin and/orincreased resistance to the action of insulin by certain cells. Glucose isthe body's main fuel. When you eat carbohydrates (pasta, bread, rice,grains, fruits, and vegetables), your digestive system breaks them downinto glucose, which is released into the bloodstream so your body canuse it for energy. Glucose also gets stored in the liver as glycogen,which can later be broken down back into glucose when the bodyneeds fuel. Insulin, which is produced in the pancreas, regulates both the move-ment of glucose into the body's cells and the breakdown in the liver ofglycogen into glucose. Both actions are critical to keeping blood sugarlevels within normal ranges.
About 1.5 to 2 million people in the U.S. have a form of the disease calledtype 1 diabetes. In this condition — usually diagnosed in childhood or theearly teen years – the pancreas, over a relatively brief period of time,stops producing insulin altogether. The onset of the disease is usuallyabrupt, with severe symptoms that require immediate attention. Type 1diabetes is a so-called "autoimmune" disease, which means the bodyattacks itself. Spe cifi cally, errant immune cells damage and destroy the 4 • Consumer Reports Health Best Buy Drugs • The Oral Diabetes Drugs: Treating Type 2 Diabetes part of the pancreas that produces insulin. People with type 1 diabetesmust inject insulin every day. In type 2 diabetes, the pancreas produces enough insulin, at least in theearly years that a person has the disease. But for reasons that are stillnot well understood, the body's cells become resistant or insensitive toit. To compensate, the pancreas pumps out increasing amounts ofinsulin to normalize blood glucose levels. Over time — as long as adecade — this ever-increasing production becomes unsustainable, andthe pancreas' ability to produce insulin declines. As a result, the telltale marker — and problem — of diabetes emerges: glu-cose levels rise in the blood because it is unable to enter the body's cells.
The excess glucose is damaging to the body's tissues and leads to thesymptoms of diabetes. When the blood glucose level gets high enough,the sugar begins to appear in the urine and causes increased urination.
Elevated blood sugar puts a strain on almost every organ and manyparts of the body. Over years, it is particularly toxic to the body'sblood vessels; it causes them to thicken. This leads to problems in theeyes and kidneys, the heart, the liver, and the blood circulation sys-tem. High blood sugar also damages the nerves. Proper treatment thatkeeps blood sugar in the normal range sharply reduces the risk ofthese complications.
Again, there are many theories and ideas about the causes of type 2diabetes, and the insulin resistance that characterizes it. Studies showthe disease runs in families, meaning it has a strong genetic (heredi-tary) component. Another cause is being overweight or obese. In somecases, this can occur due to a genetic propensity, but in most cases itis due to overeating and lack of exercise. About 55 percent of peoplediagnosed with diabetes in the U.S. are overweight or obese. While recent media attention surrounding the diabetes epidemic hasfocused on its link to obesity, the statistic above shows that 45 percentof people with diabetes are not overweight, meaning that there areother causes of the disorder. Symptoms and getting tested
The symptoms of type 2 diabetes tend to develop gradually over timeand include: Frequent urination Numbness or tingling in yourhands or feet Increased thirst and hunger Slow healing of wounds and sores The Oral Diabetes Drugs: Treating Type 2 Diabetes • Consumer Reports Health Best Buy Drugs • 5 These symptoms can also be mild and/or intermittent for years. If youexperience any of these — and especially if you experience two ormore, for even a few days — you should see a doctor immediately. In the early stages of the disease, symptoms may be non-existent.
That's unfortunate because the damage to organs occurs even in theabsence of symptoms. For this reason, it's important for people whomay be at risk of diabetes to get their blood sugar levels checked reg-ularly. Those at risk include: People 65 and older People who have a condition called metabolic syndrome People who are overweight or obese Anyone with a parent or a sibling who has diabetes People who are Black Americans, Hispanic Americans, Asian Ameri -cans, Native Americans, Pacific Islanders, or Alaskan Natives Women who have had diabetes during pregnancy or a baby weigh-ing more than 9 pounds at birth If you are in one of these groups and have never had a blood sugar check,get it tested as soon as possible. There is a disagreement in the medical community about whether alladults should have their blood sugar checked periodically. The AmericanDiabetes Association advises that everyone aged 45 and over have ablood sugar test once every three years. But the highly-regarded U.S.
Preventive Services Task Force says not enough scientific evidence existsto show that such broad screening has benefits or is worth the cost.
We think the decision rests with you and your doctor and depends onan assessment of your overall health, risk factors, weight, and familyhistory. Some doctors are inclined to check the blood sugar levels ofmost people over age 45 or 50, especially if they are 10 or more poundsoverweight. Other doctors may be more conservative.
Blood sugar tests are inexpensive and easy, though they may have tobe done a few times to yield a conclusive diagnosis. The most commontest is done after an overnight fast. If your blood sugar is 126 mil-ligrams per deciliter (mg/dl) or greater after being checked on two orthree different occasions, you are considered to have diabetes. Anothertest assesses your blood sugar at any time (not just after an overnightfast). If this test indicates your blood sugar level is 200 mg/dl or aboveon two or more occasions, you are considered to have diabetes.
6 • Consumer Reports Health Best Buy Drugs • The Oral Diabetes Drugs: Treating Type 2 Diabetes Your doctor may also talk to you about a blood test known as "hemoglo-bin A1c" (pronounced hemoglobin "A," "one," "c"; usually abbreviated inprint as HbA1c and often referred to by diabetes patients as "my A1c").
This is a commonly used test to evaluate blood sugar control after treat-ment is started. But your doctor may order this test at the time of diag-nosis. There's more about this measure in the next section.
What is pre-diabetes?
In the last decade, doctors and researchers have recognized that alarge number of people in the U.S. have fasting blood sugar levelsthat are above 110 mg/dl (the upper limit of normal) but less than the126 mg/dl required for a diagnosis of diabetes. The most recent esti-mate from the Centers for Disease Control and Prevention indicatesthat 35 percent of adults 20 and older — 79 million people — haveblood glucose levels in this range and thus have what is called pre-diabetes. (It's also sometimes called borderline diabetes or impairedfasting glucose.) What concerns doctors is that a growing body of research now showsthat people with pre-diabetes have, (a) a very high risk of developingdiabetes, and (b) an elevated risk of heart disease and stroke even iftheir glucose level never rises above 126 mg/dl. In a recent analysis involving 10,428 people in Australia, those withpre-diabetes were found to have 2.5 times the risk of dying from heartdisease over a 5-year period compared to people whose blood sugarwas normal. Such findings are leading many doctors to consider drug treatmentfor people with pre-diabetes. But most doctors agree, and researchbacks it up, that dietary and lifestyle changes can be very effectivefor keeping pre-diabetes under control — before any medicines needto be prescribed.
That said, this report does not specifically address treatment of pre-dia-betes. If you are diagnosed with pre-diabetes we would urge you to talkwith your doctor about ways to alter your diet and lifestyle, and loseweight if you need to.
Lifestyle modifications have also become a mainstay of treatmentfor people with full-blown diabetes. Studies consistently show that lifestylechanges alone — especially weight loss in those who are overweight orobese — can prevent the complications of diabetes. For some people, thesechanges can eliminate or reduce the need for drugs. The next section dis-cusses this further, and you can also find more detailed information aboutlifestyle changes in our free diabetes patient power toolkit athttp://www.consumerreports.org/health/conditions-and-treatments/type-2-diabetes/patient-power-toolkit/index.htm.
The Oral Diabetes Drugs: Treating Type 2 Diabetes • Consumer Reports Health Best Buy Drugs • 7 Since many people with diabetes also have high blood pressure and/orhigh cholesterol, your doctor will aim to get those under control, too,using diet and lifestyle changes and medicines if necessary.
Oral diabetes medicines — pills you take by mouth — are thus just onetreatment among several that doctors use to help keep people with dia-betes healthy. But they are a critical part of treatment.
Today, nine classes of drugs are available to treat type 2 diabetes. Thatincludes insulin and two other types of drugs that are given by injection.
That leaves six categories of pills, which is what this report focuses on.
We evaluate and compare the drugs in all six groups. We do not evalu-ate the injectable drugs, including the newest ones, exenatide (Byetta) andliraglutide (Victoza). We also don't compare diabetes pills with treatmentwith insulin or combination treatments consisting of injectable drugs. Note that even though most people prefer to avoid injections, insulinand other injectable diabetes drugs often become necessary if diet,exercise, and pills fail to keep blood sugar under control.
Like all drugs, the names of the six diabetes drug groups and the namesof the individual medicines in those groups are not easy to pronounceor remember. We do our best in this report to keep things simple butunfortunately we can't avoid using these complex names. The table on page 9 presentsthe groups of diabetes drugs,including those now available incombination form. The table onpage 10 presents the individualdrugs, with their generic andbrand names. We indicate whetherthe class has a generic availableand whether an individual drug isavailable in generic form. Genericsare much less expensive. As you can see, the sulfonylureas,metformin, and certain alpha-glucosidase meglitinides are older medicinesnow available in generic form,while the thiazolidinediones anddipeptidyl peptidase 4 inhibitorsare newer. Certain generic dia-betes medications cost as little as$4 for a month's supply throughgeneric drug programs run bymajor chain stores, such asKroger, Sam's Club, Target, and 8 • Consumer Reports Health Best Buy Drugs • The Oral Diabetes Drugs: Treating Type 2 Diabetes Individual Drugs
Available as
Type of Drug
(Brand and generic names) a Generic?
Brands: Amaryl, Diabeta, GlynaseGlucotrol, Glucotrol XL Generics: Glimepiride, Glipizide,Glyburide Brands: Glucophage, Glucophage XR, Brands: Precose, Glyset Brands: Prandin, Starlix Dipeptidyl peptidase sulfonylureas plus Generics: known by generic names Other Combinations Actosplus Met, Avandaryl, Avandamet, Duetact, Janumet, Kombiglyze XR Walmart. For an even better bargain, you may be able to obtain athree-month supply for $10 through these programs. We note in theprice chart starting on page 22 which generic medications are avail-able through these programs. Some stores, such as CVS and Walgreens,require a membership fee to participate and might charge higher prices.
There might be other restrictions too, so check the details carefully tomake sure your drug and dose are covered.
Our evaluation of diabetes drugs is based largely on a thorough, inde-pendent review of the scientific research on diabetes drugs. One-hundredand sixty-six studies were closely examined out of thousands screened.
The review was conducted in 2010 by a team of physician researchers atthe Johns Hopkins University Evidence-based Practice Center. This teamconducted the review as part of the Effective Health Care Program spon-sored by the Agency for Healthcare Research and Quality, a federalagency. The full report is available at www.effectivehealthcare.
ahrq.gov/reports/final.cfm. Additional sources were used to update thisreview, and an analysis of selected classes of diabetes drugs conductedby the Drug Effectiveness Review Project (DERP) based at Oregon Health The Oral Diabetes Drugs: Treating Type 2 Diabetes • Consumer Reports Health Best Buy Drugs • 9 Generic Name
Brand Name (s)
Available as a Generic?
Glucotrol, Glucotrol XL* Dipeptidyl peptidase 4 inhibitors *XR=extended release, XL=long-acting & Science University. The full DERP report is available at www.ohsu.edu/xd/research/centers-institutes/evidence-based-policy-center/derp/index.cfm/. Neither the Johns Hopkins University Evidence-based Practice Center, theAgency for Healthcare Research and Quality, nor DERP are in any wayresponsible for the advice and recommendations in this report. These enti-ties also played no role in selecting our Best Buy drugs; Consumer ReportsHealth Best Buy Drugs is solely responsible for those. This report was updated in June 2011. 10 • Consumer Reports Health Best Buy Drugs • The Oral Diabetes Drugs: Treating Type 2 Diabetes What Are the Oral Diabetes Medicines and Who Needs Them?
The six types of diabetes medicines work in differ- you try diet and lifestyle modifications first — ent ways. But they all: (a) lower blood sugar levels, before you try a drug. (b) help improve the body's use of glucose, and (c)decrease the symptoms of high blood sugar.
Many people with diabetes, however, also have highblood pressure and/or elevated cholesterol, or have The complexity of the way the different diabetes been diagnosed with coronary artery or vascular drugs work defies simple explanation. But it's use- disease. If you are in this category, your doctor may ful to know the basics. prescribe a diabetes drug when you are diagnosed,along with diet and lifestyle changes and classes in The sulfonylureas and meglitinides increase the diabetes self-management. secretion of insulin by the pancreas. Indeed, so many diabetics have other conditions Metformin inhibits glucose production by the and heart disease risk factors that doctors com- liver and decreases insulin resistance. monly treat them as "multi-disease" patients whosecare and various medications must be managed The alpha-glucosidase inhibitors delay absorp- particularly closely. Because heart disease risk fac- tion of glucose by the intestine. tors, including diabetes, take a cumulative toll,medical groups and physician organizations have The thiazolidinediones decrease insulin resistance. set aggressive goals for people with diabetes whohave multiple conditions. Table 1 on page 12 pres- The dipeptidyl peptidase 4 inhibitors (Januvia and Onglyza) promote the release of insulinfrom the pancreas after eating a meal.
The aim of treatment with lifestyle changes and med-ications is to get your HbA1c lower (and keep it lower) Since the drugs work in different ways, they are and to reduce your symptoms. As mentioned already, sometimes used in combination to enhance the the HbA1c test is the one your doctor will use to track effectiveness of treatment. Indeed, more than 50 treatment success (or failure). It measures glucose percent of people with diabetes who start taking levels chemically bound to hemoglobin, a protein one type of medicine will need another type (or carried by red blood cells. Over time, high blood insulin) within three years to keep their blood sugar sugar levels cause more glucose to bind with hemo- under control. But all will also need to alter their globin, so a high HbA1c percentage indicates that diets and lifestyles as well — losing weight if need- blood sugar levels are high on average.
ed, making dietary changes (such as cutting backon carbohydrates), quitting smoking, and becoming Many experts believe that an HbA1c level below 7 more physically active.
percent is associated with a lower risk of diabetescomplications, such as kidney disease and eye dis- Evidence strongly supports the additive effect of ease that can lead to blindness. However, there is lifestyle changes plus medicines. But several stud- no definite proof that maintaining HbA1c below 7 ies also show conclusively that many people with percent helps prevent heart disease and premature diabetes can lower their blood sugar levels almost death because most studies of the oral diabetes as much with lifestyle changes alone as with med- drugs have only looked at the affects on HbA1c for icines, especially in the early stages of their disease.
a year or less.
Thus, given that (a) all the diabetes drugs have the Although shooting for an even lower HbA1c level — potential to cause side effects and (b) lifestyle below 6.5 percent — that's closer to the range found changes have benefits to your health beyond con- in healthy people who don't have diabetes has been trolling blood sugar, most doctors will recommend promoted in the past, it's now unclear whether that The Oral Diabetes Drugs: Treating Type 2 Diabetes • Consumer Reports Health Best Buy Drugs • 11 Table 1. Goals for People with Diabetes
Blood Sugar Fasting blood glucose Below 110 mg/dl (Below 100 is better) Post-meal (2-hour) blood glucose Below 180 mg/dl (Below 140 is better) Hemoglobin A1c (HbA1c) Total cholesterol LDL ("bad") cholesterol HDL ("good") cholesterol Above 40 mg/dl for men and 50 mg/dl for women Blood pressure Below 130/80 mmHg Sources: American Diabetes Association; American Association of Clinical Endocrinologists; International Diabetes Federation; National Cholesterol Education Program; Seventh Report of the
Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; recent studies.
Definitions: LDL= low-density lipoprotein cholesterol; HDL= high-density lipoprotein cholesterol; mg = milligrams; dl=deciliter of blood; mmHg = millimeters mercury.
is better for most diabetes patients. In the largest, Managing diabetes is complex because it requires most well-regarded study of this issue, people with care ful, sometimes daily attention to diet, monitoring diabetes who achieved an average HbA1c level of blood sugars, and sometimes frequent adjustment of 6.4 percent over 3.5 years had an increased risk of me di cation doses. It is also very important to get regu - death and no reduction in heart attacks or deaths lar foot and eye exams and, if necessary, treatment for from heart disease compared with patients whose high blood pressure and cholesterol — all of which are HbA1c was maintained at 7.5 percent.
proven methods to reduce complications of diabetes. Also, two other studies did not find an increased A formal program or a conscientious primary care risk of death in patients who maintained their doctor can help you manage diabetes appropriately.
HbA1c below 6.5 percent. But these studies wereconsistent with the one described just above in that Safety and Side Effects
they also failed to show a reduction in cardiovas-cular events (like a heart attack) or deaths. All the diabetes medicines can have side effects.
Those vary from drug class to drug class and med- Given these results and the evolving science, the icine to medicine. Generally, the risks posed by dia- American Diabetes Association and other diabetes betes drugs are not an impediment to using them if experts now recommend keeping HbA1c around or you truly need one.
below 7 percent for most patients, but not below6.5 percent. Also, a higher HbA1c goal may be Even so, side effects can keep people from taking appropriate for certain patients, including those their diabetes pills. On average, 10 to 20 percent of with a history of repeated episodes of low blood people with diabetes stop taking their pills due to sugar, coronary heart disease, stroke or limited life side effects. It's important to discuss any side effects you experience with your doctor.
12 • Consumer Reports Health Best Buy Drugs • The Oral Diabetes Drugs: Treating Type 2 Diabetes Since many people with diabetes are trying to lose Side Effects of Oral Diabetes Drugs
weight, this side effect can also be very frustrating. Most of the side effects listed here ease over time or The box on this page gives a general run down of stop when the medication is discontinued. However, a the side effects linked to diabetes drugs. The poten- few can be permanent in certain people tial side effects of each drug are discussed at morelength in the next section, which also compares the drugs across a range of criteria (including their Hypoglycemia or low blood sugar (usually minor if
cost) and presents our Best Buy choices. caught in time but can be serious or fatal if not treat- ed; symptoms include profuse sweating, tremor, shakiness, dizziness, hunger. When serious, includes mental confusion, coma, and risk of stroke or death) Weight gain
Gastrointestinal side effects (abdominal pain, nausea,
vomiting, diarrhea, gassiness, and bloating) Edema (fluid in legs and ankles)
Increase in "bad" cholesterol (LDL)
Congestive heart failure
Anemia (low red blood cell counts)
Allergic reactions
Thrombocytopenia (low blood platelet counts)
Lactic acidosis (build up of acid in the blood)
Leukopenia (low white blood cell counts)
Macular edema (eye problems)
Liver disease/liver failure
Most notably, some diabetes drugs can cause lowblood sugar, or hypoglycemia. This is a dangerousside effect and one that leads some doctors to pre-scribe one diabetes drug over another. The symptomsof hypoglycemia are listed in the box on this page.
Unfortunately, some people do not have minor symp-toms to warn them that their blood sugar is gettingdangerously low. That's one reason your doctor willemphasize to you that you must check your bloodsugar regularly. Another worrisome side effect of some of the diabetesdrugs is weight gain, or difficulty losing weight.
The Oral Diabetes Drugs: Treating Type 2 Diabetes • Consumer Reports Health Best Buy Drugs • 13 Choosing an Oral Diabetes Medicine — Our Best Buy Picks
The good news is that the diabetes drugs have been medicines — acarbose, miglitol, nateglinide, and compared to each other in many good studies, and sitagliptin — decrease HbA1c less than the some of the drugs have been used for years and other drugs.
helped millions of people. The bad news is thatmost of the careful studies have not tracked the The newer drugs are no safer. As discussed in effects of the drugs (pro and con) over many years.
the previous sections and presented in Tables 2, Most followed people for just a year or less.
3 and 4, all diabetes pills have the potential tocause adverse effects — both minor and serious. Even so, the studies help clarify the benefits andadverse effects of most diabetes drugs, and signal Metformin emerges as a superior drug based on typi cal and expected effects among a group of people the available evidence. This medicine lowers with diabetes. But very importantly, such studies do HbA1c the same amount or more than other not reveal how a specific person with diabetes will diabetes drugs, does not cause weight gain, respond to any particular drug. Only your doctor and decreases low-density lipoprotein (LDL) choles- you can decide precisely which drug or drug combi- terol and triglycerides, and appears to have the nation is best for you given your health status, safest profile when comparing serious side weight, other medical needs, and the severity of your effects in people who do not have kidney, liver, diabetes. And only you and your doctor can track or heart disease. As further discussed below, how well a particular drug or combination of drugs is however, certain patients should not take met- helping you, or not helping you.
Tables 2, 3 and 4 on pages 17, 18, and 20, respec- Taking two diabetes drugs can have a positive tively, summarize the comparative evidence on the additive affect on reducing HbA1c. This is a diabetes drugs. The tables reflect the results from major plus for the many people with diabetes 166 studies. Table 2 presents summary evidence of whose blood glucose is not well controlled by a the various classes of diabetes drugs. Table 3 is single drug. The downside is that taking two more specific, with detailed information on the drugs poses a higher risk of side effects. If lower individual drugs. As such, Table 3 takes a bit more doses of each drug are used in combination, the time to figure out. But it contains information added risk of side effects often can be reduced. unique to this report and which may be valuablefor your treatment decision. The newer drugs are more expensive. The neweroral diabetes medicines cost many times more Table 4 presents a run-down of the pros and cons than the older ones (See Table 5 beginning on of each drug class. The tables contain some mate- rial that is duplicative. On balance, though, theygive you three ways to assess the important differ-ences among diabetes drugs.
As mentioned earlier, the diabetes drugs have dis-tinctly different "safety profiles." This factor may Our evaluation leads to the following overall be the primary driver of your and your doctor's decision — for initial and on-going treatment.
The newer drugs are no better. The thiazolidine- For example, the evidence clearly shows that the diones, meglitinides, alpha-glucosidase in hibitors, sulfonylureas pose a higher risk of hypoglycemia and dipeptidyl peptidase 4 inhibitors (all more than metformin or the thiazolidinediones (Avandia recently developed) are no more effective than the and Actos). Specifically, between 9 and 22 percent sulfonylureas and metformin (which have been of people taking one of the sulfonylurea drugs can around for decades). In fact, four of the newer expect to have an episode of potentially dangerous 14 • Consumer Reports Health Best Buy Drugs • The Oral Diabetes Drugs: Treating Type 2 Diabetes low blood sugar, compared to zero to 7 percent tak- the FDA has restricted use of the medication (and ing metformin.
combination products that contain it) only for peo-ple who have persistent high blood sugar levels The risk of hypoglycemia is about the same for the even after taking another medication and who can't sulfonylureas and repaglinide (Prandin), but two take an alternative such as Actos. As of November recent studies suggest that repaglinide may cause 18, 2011, Avandia and combination products, less hypoglycemia in seniors or in people who skip Avandamet and Avandaryl, will no longer be available at pharmacies. Instead, both you and yourdoctor will have to register with a special program As good as it looks in other ways, metformin has to have them delivered by mail-order.
been associated with rare occurrences of lactic aci-dosis — a build up of lactic acid in the blood that If you are already taking Avandia, Avandamet or can be fatal. This rare risk appears to exist mostly Avandaryl, and they are working to control your for people with diabetes who also have kidney dis- blood sugar, you can continue to take them, but we ease and/or heart failure. As a result, such patients strongly recommend you discuss with your doctor should not be prescribed metformin.
whether they are appropriate for you.
Minor but annoying side effects may also play a Both Actos and Avandia have also been linked to a role in your choice of a diabetes medicine. For slightly increased risk of fractures of the upper and example, gastrointestinal side effects — including lower limbs, such as the wrist or ankle, in women.
bloating, gas, nausea, and diarrhea — are more fre- The risk was small — about 2 percent higher in peo- quent with metformin and also acarbose.
ple taking Avandia or Actos compared with thosetaking other diabetes drugs, according to prelimi- One of the newer classes of drugs poses an elevat- nary studies.
ed risk of heart failure. Evidence overwhelminglyindicates that the thiazolidinediones — Avandia Actos increases the risk of bladder cancer in people (more about it below) and Actos — pose a 1.5 to 2 who take it for a year or longer. The risk applies to all times increased risk of congestive heart failure drugs containing pioglitazone, including Actoplus compared to other diabetes medicines. Between 1 Met, Actoplus Met XR, and Duetact. France banned and 3 people in 100 without a history of heart dis- Actos and combination pills due to the cancer risk. ease will develop the condition if they take one ofthese drugs. In contrast, metformin and the sul- Our medical advisors say that people with diabetes fonylureas do not raise the risk of heart failure in should use Actos only as a last resort, which means any significant way compared to the general risk of only if all other options have failed. People who this condition among people with diabetes, which have previously had or currently have bladder can- is higher than normal.
cer should not use Actos or the combination pillsthat contain it at all.
Because of the clear evidence of heart failure risk,both Actos and Avandia carry a high-profile "black If you're on Actos, ask your doctor if it's really nec- box" warning about it on their labels (guidance to essary and if you should switch to another drug, doctors and patients on how to use them). If you such as metformin either alone or in combination are taking one of these medicines and have with glipizide or glimepiride. Also, be alert for swelling of any part of your body, sudden weight signs of bladder cancer, which include blood or red gain, or breathing problems, you should contact color in your urine, urgent need to urinate or pain your doctor immediately.
while urinating, and pain in your back or lowerabdomen. Contact your doctor if you experience Don't Take Avandia; Actos a Last Resort
any of those symptoms.
In addition to heart failure, Avandia also increases Actos has been heavily promoted to doctors and the risk of heart attack and stroke. For that reason, consumers in the U.S. As a result, it may be over- The Oral Diabetes Drugs: Treating Type 2 Diabetes • Consumer Reports Health Best Buy Drugs • 15 prescribed to people who would do just as well to If upon initial diagnosis your glucose and HbA1c take metformin and/or a sulfonylurea. Both Actos are quite high, you may be prescribed a combina- and Avandia (until recently) have been marketed tion of two drugs at the beginning of treatment — specifically to minorities as well, but there is no usually metformin plus a sulfonylurea.
good evidence that any diabetes medicine is moreeffective or safer in African-Americans, Hispanics, Januvia and Onglyza — the newest oral diabetes
or American Indian patients than in other ethnic Januvia and Onglyza are the first two drugs in a new Our picks and recommendations
class of diabetes medications called dipeptidyl pepti-dase 4 inhibitors. No studies on these drugs have Taking effectiveness, safety, side effects, dosing, followed patients for more than two years, so their and cost into consideration, we have chosen the effectiveness and safety profiles are not clearly following as Consumer Reports Health Best Buy established yet. Neither Januvia nor Onglyza has Drugs if your doctor has decided that you need been shown to lower HbA1c as well as metformin or medicine to control your diabetes: glipizide, so we do not recommend them as first-linedrugs. Another drawback is that both are signifi- Metformin and Metformin Sustained Release — cantly more expensive than generic versions of other alone or with glipizide or glimepiride diabetes drugs.
Glipizide and Glipizide Sustained Release — Finally, as a reminder, if your diabetes is not con- alone or with metformin trolled by pills, you may have to take insulin or oneof the newer drugs available by injection only. Glimepiride — alone or with metformin All these medicines are available as low-cost gener-ics, either alone or in combination. (See Table 5.) Inrecent years, a strong medical consensus hasemerged in the U.S., Europe, and Australia that mostnewly diagnosed people with diabetes who need amedicine should first be prescribed metformin.
Based on the systematic evaluation of diabetesdrugs that forms the basis of this report, we concurwith that advice. Unless your health status preventsit, try metformin first. If metformin fails to bringyour blood glucose into normal range, you mayneed a second drug. Most commonly that should beone of the two other Best Buys we have chosen.
If you are unable to take metformin or do nottolerate it well, you face a choice of one of thesulfonylureas or a newer medicine as your first linemedicine. Despite the elevated risk of hypo-glycemia, we recommend trying glipizide orglimepiride. If glipizide or glimepiride alone fail tobring your blood glucose into control and keepyour HbA1c at or below 7 percent, your doctor willlikely recommend a second drug. 16 • Consumer Reports Health Best Buy Drugs • The Oral Diabetes Drugs: Treating Type 2 Diabetes Table 2. Summary of Comparative Effectiveness of Oral Diabetes Drugs
Metformin vs.
No difference Sulfonylureas No difference Not enough Blood Pressure No difference
LDL (bad)
No difference Not enough Metformin better HDL (good)
No difference Not enough No difference Not enough One thiazolidinedione Not enough DPP-inhibitors No difference Risk of GI
Metformin better Heart Failure
Risk of Anemia Not enough
Metformin better Risk of Edema
Metformin better (fluid build-up) evidence
Risk of Bone
Metformin better Source: 1. Bolen S., et al, Comparative Effectiveness and Safety of Oral Diabetes Medications for Adults with Type 2 Diabetes. http://www.effectivehealthcare.ahrq.gov/reports/final.cfm.
2. Bennett WL, et al, Oral Diabetes Medications for Adults With Type 2 Diabetes: An Update. Comparative Effectiveness Review No. 27. March 2011 (Prepared by Johns Hopkins UniversityEvidence-based Practice Center under Contract No. 290-02-0018.) AHRQ Publication No. 11-EHC038-EF. Rockville, MD: Agency for Healthcare Research and Quality. March 2011. Availableat: www.effectivehealthcare.ahrq.gov/reports/final.cfm.
Definitions: "No difference" means that adequate or good studies have been done and when considered as a whole have found no difference between these two categories of drugs. "Not enough
evidence" means not enough studies have been done, or the studies that have been done are not good enough to warrant a judgment about any differences between these two classes of drugs.
1. For repaglinide (Prandin) only.
2. Pioglitazone (Actos) decreased triglycerides while rosiglitazone (Avandia) increased triglycerides; thus, Actos showed similar effects to the sulfonylureas while Avandia was worse than the sul- fonylureas. But no direct comparisons were available to draw firm conclusions. 3. Pioglitazone (Actos) was better than metformin while rosiglitazone (Avandia) was worse.
4. Pioglitazone was better than metformin.
The Oral Diabetes Drugs: Treating Type 2 Diabetes • Consumer Reports Health Best Buy Drugs • 17 Table 3. Effects of Oral Diabetes Drugs on Specific Measures
A down arrow () means a decrease or decline; an up arrow () means increase; and a diamond () means no
meaningful effect or change. IE = Insufficient Evidence. Brand names are not given for drugs available as generics.

change in
change in
change in
weight (lbs)
Dipeptidyl peptidase IV inhibitor 0.6-0.8
18 • Consumer Reports Health Best Buy Drugs • The Oral Diabetes Drugs: Treating Type 2 Diabetes Table 3. Effects of Oral Diabetes Drugs on Specific Measures (continued)
A down arrow () means a decrease or decline; an up arrow () means increase; and a diamond () means no
meaningful effect or change. IE = Insufficient Evidence. Brand names are not given for drugs available as generics.

point change absolute
change in
change in
weight (lbs)
Selected Combinations Metformin +sulfonylurea 1.7-2.3
Metformin +rosiglitazone 1.3-2.0
Definitions/Key: No meaningful change; Significant decrease; Significant increase; IE=insufficient data; lbs=pounds; mg/dl=milligrams per deciliter of blood; mmHg=millimeters mer-
cury; HbA1c=hemoglobin A1c; LDL=low-density lipoprotein cholesterol; HDL= high-density lipoprotein cholesterol.
1. Results mostly come from short-duration studies lasting 3 months to 1 year. There are only a few studies longer than one year which show slightly higher rates of hypoglycemia but similar comparative results. 2. IE = insufficient evidence for this drug on this measure to reach any meaningful conclusions.
3. Results based on one short-term study (<1 year).
4. Results are based on data from a systematic review plus a large randomized study.
5. Results are based on data from two studies.
The Oral Diabetes Drugs: Treating Type 2 Diabetes • Consumer Reports Health Best Buy Drugs • 19 Table 4. Advantages and Disadvantages of the Oral Diabetes Drugs
The sulfonylureas (glyburide, glimepiride, glipizide)
Fast onset of action
Weight gain (5 to 10 pounds on average)
No affect on blood pressure
Heightened risk of hypoglycemia
No affect on LDL cholesterol
Glyburide has slightly higher risk of hypoglycemia
Convenient dosing
compared with glimepiride and glipizide Low cost
Lower risk of GI side effects than metformin
Low risk of hypoglycemia
Higher risk of GI side effects (nausea and diarrhea)
Not linked to weight gain
Cannot be taken by people with diabetes who have
Good effect on LDL cholesterol
moderate or severe kidney disease or heart failurebecause of risk of lactic acid build-up Good effect on triglycerides
Less convenient dosing
No effect on blood pressure
Low cost
The alpha-glucosidase inhibitors (acarbose, miglitol)
Slightly lower risk of hypoglycemia compared to
Less effective than most other diabetes pills in lowering
Not associated with weight gain
Higher risk of GI side effects than other diabetes pills except
Decreases triglycerides
No effect on cholesterol
Inconvenient dosing
High cost
The thiazolidinediones (Actos, Avandia)
Low risk of hypoglycemia
Higher risk of heart failure
Slight increase in "good" (HDL) cholesterol
Weight gain (5 to 10 pounds)
Actos linked to decreased triglycerides
Linked to higher risk of edema (fluid build-up)
Convenient dosing
Linked to higher risk of anemia
Increase in "bad" (LDL) cholesterol
Avandia linked to increased triglycerides and
higher risk of heart attack Actos linked to increased risk of bladder cancer
Slower onset of action
Rare risk of liver problems; requires monitoring
Linked to increased risk of upper and
lower limb fractures High cost
20 • Consumer Reports Health Best Buy Drugs • The Oral Diabetes Drugs: Treating Type 2 Diabetes Table 4. Advantages and Disadvantages of the Oral Diabetes Drugs (continued)
The meglitinides (nateglinide, repaglinide)
No bad effect on cholesterol
Repaglinide associated with risk of hypoglycemia and
Rapid onset of action
weight gain similar to sulfonylureas Nateglinide has less effect on HbA1c
Inconvenient dosing
High cost
The DPP-inhibitors (Januvia, Onglyza)
When added to metformin, lower risk of hypoglycemia
Reduce HbA1c less than several other diabetes drugs
compared with a sulfonylurea May only be valuable as second drugs added to another
Few known side effects (but they are new drugs)
Lower risk of GI side effects than metformin
Less data on potential side effects compared to older drugs
Convenient dosing
High cost
1. Bennett WL, et al, Oral Diabetes Medications for Adults With Type 2 Diabetes: An Update. Comparative Effectiveness Review No. 27. March 2011 (Prepared by Johns Hopkins University Evidence-based Practice Center under Contract No. 290-02-0018.) AHRQ Publication No. 11-EHC038-EF. Rockville, MD: Agency for Healthcare Research and Quality. March 2011. Available at:www.effectivehealthcare.ahrq.gov/reports/final.cfm.
2. Bennett WL., et al, Comparative effectiveness and safety of medications for type 2 diabetes: an update including new drugs and 2-drug combinations. Ann Int Med. (May 3 2011); Web pub- lished in advance of print publication, March 14, 2011.
The Oral Diabetes Drugs: Treating Type 2 Diabetes • Consumer Reports Health Best Buy Drugs • 21 Table 5: Cost of Oral Diabetes Drugs
Note: If the price box contains a $ , that indicates the dose of that drug is available for a low monthly cost through programs offered
by large chain stores. For example, Kroger, Sam's Club, Target, and Walmart offer a month's supply of selected generic drugs for $4 or a
three-month supply for $10. Other chain stores, such as Costco, CVS, Kmart, and Walgreens, offer similar programs. Some programs
have restrictions or membership fees, so check the details carefully for restrictions and to make sure your drug is covered.
Generic Name
Brand Name
Number of Pills
Total Daily Dose1
(or Generic)
(Per day)1
Glyburide 1.25 mg Glyburide micronized 6 mg Glyburide micronized 6 mg Glipizide 5 mg, sustained release Glipizide 5 mg, sustained release Glipizide 10 mg sustained release Glipizide 10 mg, sustained release 22 • Consumer Reports Health Best Buy Drugs • The Oral Diabetes Drugs: Treating Type 2 Diabetes Table 5: Cost of Oral Diabetes Drugs (continued)
Generic Name
Brand Name
Number of Pills
Total Daily Dose1
(or Generic)
(Per day)1
Metformin 1000 mg Metformin 1000 mg Metformin sustained release 500 mg Metformin sustained release 500 mg Metformin sustained release 750 mg Metformin sustained release 750 mg Saxagliptin 2.5 mg Sitagliptin 100 mg Sitagliptin 50 mg Pioglitazone 15 mg Pioglitazone 30 mg Pioglitazone 45 mg Rosiglitazone 2 mg Rosiglitazone 4 mg Rosiglitazone 8 mg Repaglinide 0.5 mg Nateglinide 60 mg Nateglinide 60 mg Nateglinide 120 mg Nateglinide 120 mg Metformin+glipizide 250 mg/2.5 mg Metformin+glipizide 500 mg/2.5 mg Metformin+glipizide 500 mg/5 mg Metformin+glyburide 250 mg/1.25 mg Generic Metformin+glyburide 500 mg/2.5 mg Metformin+glyburide 500 mg/2.5 mg Metformin+glyburide 500 mg/5 mg The Oral Diabetes Drugs: Treating Type 2 Diabetes • Consumer Reports Health Best Buy Drugs • 23 Table 5: Cost of Oral Diabetes Drugs (continued)
Generic Name
Brand Name
Number of Pills
Total Daily Dose1
(or Generic)
(Per day)1
Metformin+glyburide 500 mg/5 mg Pioglitazone+metformin 15 mg/850 mg Actoplus Met Pioglitazone+metformin 15 mg/500 mg Actoplus Met release 15 mg/1000 mg release 30 mg/1000 mg Pioglitazone+glimepiride 30 mg/2 mg Pioglitazone+glimepiride 30 mg/4 mg Repaglinide+metformin 1 mg/500 mg Repaglinide+metformin 2 mg/500 mg Rosiglitazone+glimepiride 4 mg/1 mg Rosiglitazone+glimepiride 4 mg/2 mg Rosiglitazone+glimepiride 4 mg/4 mg Rosiglitazone+glimepiride 8 mg/2 mg Rosiglitazone+glimepiride 8 mg/4 mg Rosiglitazone+metformin 1 mg/500 mg Rosiglitazone+metformin 2 mg/500 mg Rosiglitazone+metformin 2 mg/1000 mg Avandamet Rosiglitazone+metformin 4 mg/500 mg Rosiglitazone+metformin 4 mg/1000 mg Avandamet Saxagliptin+metformin 2.5 mg/1000 mg Saxagliptin+metformin 5 mg/500 mg Saxagliptin+metformin 5 mg/1000 mg Sitagliptin+metformin 50 mg/500 mg Sitagliptin+metformin 50 mg/1000 mg * For space reasons, not all doses are listed.
1. As usually recommended.
2. Prices reflect nationwide retail average for April 2011, rounded to the nearest dollar. Information derived by Consumer Reports Health Best Buy Drugs from data provided by Wolters Kluwer Pharma Solutions, which is not involved in our analysis or recommendations. 24 • Consumer Reports Health Best Buy Drugs • The Oral Diabetes Drugs: Treating Type 2 Diabetes Talking With Your Doctor
It's important for you to know that the information we present in this report is not meant to substitute for adoctor's judgment. But we hope it will help your doctor and you arrive at a decision about which diabetes drugand at what dose is best for you. Bear in mind that many people are reluctant to discuss the cost of medicines with their doctors and that stud-ies show doctors do not routinely take price into account when prescribing medicines. Unless you bring it up,your doctors may assume that cost is not a factor for you.
Many people (including many physicians) also believe that newer drugs are always or almost always better.
While that's a natural assumption to make, the fact is that it's not true. Studies consistently show that manyolder medicines are as good as, and in some cases better than, newer medicines. Think of them as "tried andtrue," particularly when it comes to their safety record. Newer drugs have not yet met the test of time, andunexpected problems can and do crop up once they hit the market.
Of course, some newer prescription drugs are indeed more effective and safer. Talk with your doctor about thepluses and minuses of newer versus older medicines, including generic drugs.
Prescription medicines go "generic" when a company's patents on a drug lapse, usually after about 12 to 15years. At that point, other companies can make and sell the drug.
Generics are almost always much less expensive than newer brand name medicines, but they are not lesserquality drugs. Indeed, most generics remain useful medicines even many years after first being marketed. Thatis why today more than 60 percent of all prescriptions in the U.S. are for generics.
Another important issue to talk with your doctor about is keeping a record of the drugs you are taking. Thereare several reasons for this: First, if you see several doctors, they may not always tell each other which drugs have been prescribed for you.
Second, it is very common for doctors today to prescribe several medicines for you before finding one thatworks well or best, mostly because people vary in their response to prescription drugs.
Third, more and more people today take several prescription medications, nonprescription drugs and supple-ments all at the same time. Many of these interact in ways that can be very dangerous. And fourth, the names of prescription drugs—both generic and brand—are often hard to pronounce andremember.
For all these reasons, it's important to keep a list of the drugs you are taking, both prescription and nonpre-scription and including dietary supplements.
Always be sure, too, that you understand the dose of the medicine being prescribed for you and how many pillsyou are expected to take each day. Your doctor should tell you this information. When you fill a prescription atthe pharmacy, or if you get it by mail, you may want to check to see that the dose and the number of pills perday on the pill bottle match the amounts that your doctor told you.
The Oral Diabetes Drugs: Treating Type 2 Diabetes • Consumer Reports Health Best Buy Drugs • 25 How We Conducted Our Review of the Oral Diabetes Drugs
Our evaluation is based in large part on an inde- The prescription drug costs we cite were obtained pendent review of the scientific evidence on the from a healthcare information company that tracks effectiveness, safety, and adverse effects of the oral the sales of prescription drugs in the U.S. Prices for diabetes medicines conducted by the Johns a drug can vary quite widely, even within a single Hopkins University-evidence based Practice Center city or town. All the prices in this report are nation- under contract number 290-02-0018 with the al averages based on sales of prescription drugs in Agency for Healthcare Research and Quality. This retail outlets. They reflect the cash price paid for a analysis reviewed hundreds of studies, including month's supply of each drug in April 2011.
those conducted by the drugs' manufacturers. Asynopsis of the results of this analysis, written by Consumers Union and Consumer Reports selected the researchers at Johns Hopkins, forms the basis of the Best Buy Drugs using the following criteria. The portions of this report. However, no statement in this report should be con- Be as effective or more effective than other oral strued as the official position of the Johns Hopkins diabetes medicines Evidence-based Practice Center, the Agency forHealth care Research and Quality, or the U.S. De part - Have a safety record equal to or better than ment of Health and Human Services. In particular, other oral diabetes medicines none of those entities played any role in our selectionof the Best Buy diabetes drugs. Con sumer Reports, Cost roughly the same or less than other oral publishers of Consumer Reports Health Best Buy diabetes medicines Drugs, is solely responsible for those, and for all otherspecific advice and recommendations in this report.
The Consumer Reports Health Best Buy Drugs method- Additional sources used in writing this report ology is described in more detail in the methods sec- An analysis of selected classes of diabetes drugsconducted by the Drug Effectiveness ReviewProject (DERP), an initiative to evaluate thecomparative effectiveness and safety of hun-dreds of prescription drugs.
Three reviews of oral diabetes drugs by theCochrane Collaboration An American Medical Association monographon the oral diabetes drugs A Veteran's Administration monograph on dia-betes drugs Recent guidelines issued by the American DiabetesAssociation and American College of Cardiology Selected recent articles in peer-reviewed jour-nals (See References) 26 • Consumer Reports Health Best Buy Drugs • The Oral Diabetes Drugs: Treating Type 2 Diabetes Consumers Union, publisher of Consumer Reports® Education Grant Program, which is funded by the magazine, is an independent and non-profit organi- multi-state settlement of consumer fraud claims zation whose mission since 1936 has been to provide regarding the marketing of the prescription drug consumers with unbiased information on goods and services and to create a fair marketplace. ConsumersUnion's main Web site is ConsumerUnion.org. The The Engelberg Foundation provided a major grant magazine's Web site is ConsumerReports.org. Our to fund the creation of the project from 2004 to new health Web site is ConsumerReportsHealth.org.
2007. Additional initial funding came from theNational Library of Medicine, part of the National Consumer Reports Health Best Buy Drugs™ is a pub- Institutes of Health. lic education project administered by ConsumersUnion. These materials are made possible by the A more detailed explanation of the project is avail- state Attorney General Consumer and Prescriber able at ConsumerReportsHealth.org.
Sharing this Report
This report should not be viewed as a substitute for Your use of this report is also subject to our User a consultation with a medical or health profession- Agreement available at ConsumerReportsHealth.org/ al. The information is meant to enhance communi- BestBuyDrugs. The reports are intended solely for cation with your doctor, not replace it. Use of our your personal, noncommercial use and may not be drug reports is also at your own risk. Consumers used in advertising, promotion or for any other com- Union can not be liable for any loss, injury, or mercial purpose. You are free to download, copy, and other damages related to your use of this report.
distribute the reports for individual and family use.
You may not modify or create derivate works from You should not make any changes in your medi- the text of the reports, however, or remove any copy- cines without first consulting a physician.
right or trademark notices. Any organization inter-ested in broader distribution of this or any of our We followed a rigorous editorial process to ensure reports in print or on the Internet should contact us that the information in this report and on the at crbestbuydrugs@cu.consumers.org. All quotes Consumer Reports Health Best Buy Drugs website is from the reports should cite Consumer Reports Health accurate and describes generally accepted clinical Best Buy Drugs™ as the source. Consumer Reports practices. If we find, or are alerted to, an error, we Health Best Buy Drugs™, Consumers Union® and will correct this as quickly as possible. However, Consumer Reports® are trademarks of Consumers Consumer Reports and its authors, editors, publish- Union of U.S., Inc.
ers, licensors and any suppliers cannot be responsi-ble for medical errors or omissions, or any conse- 2011 Consumers Union of U.S., Inc. quences from the use of the information on this site. The Oral Diabetes Drugs: Treating Type 2 Diabetes • Consumer Reports Health Best Buy Drugs • 27 1. Bennett W.L., et al, Oral Diabetes Medications for Adults With Type 2 Diabetes: An Update.
25. "Global guidelines for type 2 diabetes: recommendations for standard, comprehensive, and Comparative Effectiveness Review No. 27. March 2011 (Prepared by Johns Hopkins minimal care. Diabetes Med (2006); Vol. 23(6), pages 579-593.
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2. Bennett W.L., et al, Comparative effectiveness and safety of medications for type 2 dia- 27. Holman R.R., et al, "A randomized double-blind trial of acarbose in type 2 diabetes shows betes: an update including new drugs and 2-drug combinations. Ann Int Med. (May 3 improved glycemic control over 3 years," (The UK Prospective Diabetes Study). Diabetes 2011); Web published in advance of print publication, March 14, 2011.
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Association of Clinical Endocrinologists Medical (May/June 2007). Available at 33. Kahn S.E., et al., "ADOPT Study Group: Glycemic durability of rosiglitazone, metformin, or glyburide monotherapy." N Engl J Med. (2006): Vol. 355, pages 2427-2443.
9. Diabetes Overview, National Diabetes Information Clearinghouse. Accessed June 22, 2007.
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19. Dabelea, D. et al, "Incidence of diabetes in youth in the United States," JAMA (June 27, 43. Nathan D.M., et al, "Medical Management of Hyperglycemia in Type 2 Diabetes: a 2007): Vol. 297, No 24, pages 2716-2724. Consensus Algorithm for the Initiation and Adjustment of Therapy," Diabetes Care. (2009): 20. Amori, R.E. et al, "Efficacy and safety of incretin therapy in type 2 diabetes — systematic Vol. 32(1), pages 193-203.
review and meta-analysis," JAMA (July 11, 2007): Vol. 298, No. 2, pages 194-206 44. 52-week add-on to Metformin Comparison of Saxagliptin and Sulphonylurea, With a 52-week 21. "Sitagliptin/Metformin (Janumet) for Type 2 Diabetes," The Medical Letter on Drugs and Extension Period. Study NCT00575588, accessed 9 May 2011 http://clinicaltrials.gov/ct2/show/ Therapeutics (June 4, 2007): Vol. 49, Issue 1262, page 1. 22. "Intensive blood-glucose control with sulphonylureas or insulin compared with conven- tional treatment and risk of complications in patients with type 2 diabetes," The UKProspective Diabetes Study Group." Lancet (1998): Vo. 352 (9131), pages 837-853.
23. "A randomized trial of efficacy of early addition of metformin in sulfonylurea-treated type 2 diabetes." The UK Prospective Diabetes Study Group. Diabetes Care (1998): Vol 21 (1),pages 87-92.
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28 • Consumer Reports Health Best Buy Drugs • The Oral Diabetes Drugs: Treating Type 2 Diabetes

Source: http://consumerhealthchoices.org/wp-content/uploads/2012/08/BBD-Diabetes-Full.pdf

Pattern of antimicrobial prescription and its cost

KATHMANDU UNIVERSITY JOURNAL OF SCIENCE, ENGINEERING AND TECHNOLOGY VOL.I, No.1, SEPTEMBER, 2005. PATTERN OF ANTIMICROBIAL PRESCRIPTION AND ITS COST ANALYSIS IN RESPIRATORY TRACT INFECTION Sushma Dawadi, B.S.Rao, G.M.Khan Department of Pharmacy Kathmandu University, Dhulikhel, Kavre, P.O. Box: 6250, Kathmandu, Nepal. Corresponding author E-Mail:pharmacy@ku.edu.np, profsrao@ku.edu.np


N° 02 2012 Fr. 12.– LE MAGAZINE DES MÉDIAS „Il faut parler aux jeunes" La guerre des Comment Raymond Loretan magazines fémininsAu moins quatre titres vont Les médias suisses voit l'avenir de la TV se partager la Suisse romande cherchent leurs marques