So, in summary, when we're looking at all of our drugs in diabetes - not just the SGLT2s -
the first line agent right now is still metformin. Part of the reason is because of cost.
It’s a cheap drug, it really works well, it increases insulin sensitivity,
and the side effect profile is quite acceptable.
The TZDs and the secretagogues like sulfonylureas are really falling out of favor.
We've seen a lot of side effects with them
and we've also seen that they don’t really reduce mortality like some of the other agents.
Alpha glucosidase inhibitors have essentially disappeared from the therapeutic landscape
because of the multiple side effects that patients have
but I don’t want you to get the idea that we don’t use them at all.
It’s just that we have other better choices out there but if you're in a pickle
and you really need to treat your patients you can use an AGI.
The DPP4s are very safe.
They're often combined with metformin
and from a practical point of view they are often second line agents at this point in time
but I think that’ll change with the new SGLT2s because they're the exciting new drug class.
They have evidence of heart failure reduction, they may have evidence of renal improvement
and I think they’re the most exciting thing that’s happened to diabetes probably in 20 - 30 years.
They should not be used in volume depleted patients.
And, finally, insulin is the mainstay of type 1 diabetics and diabetic ketoacidosis;
and of course insulin is not a bad drug, it’s a very good drug when used appropriately.