Managed care perspective on three new agents for type 2 diabetes

Area of Science:

• Endocrinology
• Pharmacology
• Metabolic Diseases

Background:

• Many type 2 diabetes patients require additional medications beyond monotherapy to achieve target A1C levels.
• Three novel therapeutic agents—pramlintide, exenatide, and sitagliptin—were approved for type 2 diabetes treatment between 2005 and 2006.

Purpose of the Study:

• To review the efficacy and safety of exenatide, pramlintide, and sitagliptin for type 2 diabetes management.
• To define the therapeutic role of these new agents, considering their cost and unknown long-term outcomes.

Main Methods:

• A comprehensive MEDLINE search was conducted for English-language studies on type 2 diabetes, exenatide, pramlintide, and sitagliptin.
• Systematic reviews, meta-analyses, and reference citations were used to supplement the search.

Main Results:

• Exenatide and pramlintide injections, and sitagliptin oral administration, demonstrated modest A1C reductions (0.5%-1.0%).
• Exenatide and pramlintide are associated with modest weight loss and a high incidence of nausea; pramlintide carries a risk of severe hypoglycemia when used with insulin.
• Sitagliptin, an oral agent, showed modest A1C reduction but has unknown long-term safety and potential for severe allergic reactions.

Conclusions:

• The three new agents provide modest A1C reduction compared to older treatments and insulin.
• Long-term safety and efficacy remain unknown, and these agents are significantly more expensive than generic first-line therapies.
• Their use should be limited to select patients inadequately controlled by established, cost-effective treatments with known long-term profiles.