Problem Is the problem a priority? | ||
Judgment | Research evidence | Additional considerations |
Yes | Specific recommendations for patients with prior cardiovascular events are provided by some guidelines23−26. The absolute risk of cardiovascular events and all-cause mortality is particularly increased in patients with type 2 diabetes and established cardiovascular disease. The risk reduction observed with some classes of drugs for diabetes could therefore produce very relevant benefits in this subset of patients with diabetes | |
Desirable Effects How substantial are the desirable anticipated effects? | ||
Judgment | Research evidence | Additional considerations |
Varies |
Effects of different classes of drugs, as reported in direct comparisons27 (only statistical significant results are reported): 52-week HbA1c: compared to metformin GLP-1 RA: − 0.2% Acarbose: + 0.4% 104-week HbA1c: compared to metformin SGLT-2i: − 0.2% Sulfonylureas: + 0.1% Insulin: + 0.4% Overall effects of different classes on MACE28.: Metformina: − 40%; GLP-1 RA: − 11%; SGLT-2i: − 15% Pioglitazone: − 15% SU/insulin secretagogues: + 19% Overall effects of different classes on hospitalization for heart failure 28 SGLT-2i: − 10% Pioglitazoine: + 30% Overall effects of different classes on all-cause mortality 28 : GLP-1 RA: − 12%; SGLT-2i: − 15%; Sulfonylureas: + 12% Quality of life GLP-1RA is associated with improved quality of life in comparison with DPP-4 inhibitors or insulin28 |
MACE: no trial was found for alpha-glucosidase inhibitors |
Undesirable Effects How substantial are the undesirable anticipated effects? | ||
Judgment | Research evidence | Additional considerations |
Varies | Severe hypoglycemia: Sulphonylureas increase the risk of hypoglycemia (OR: 2.7) in comparison with metformin27 |
Metformin: gastrointestinal side effects; rare cases of lactic acidosis Alpha-glucosidase inhibitors: gastrointestinal side effects Sulfonylureas: weight gain; hypoglycemia Pioglitazone: fluid retention; weight gain; heart failure; bone fracture DPP-4 inhibitors: suspected pancreatitis; rare cases of pemphigoid GLP-1RA: gastrointestinal side effects; cholelithiasis; pancreatitis SGLT-2 inhibitors: genito-urinary infections; rare keto-acidosis Insulin: hypoglycemia and weight gain |
Certainty of evidence What is the overall certainty of the evidence of effects? | ||
Judgment | Research evidence | Additional considerations |
Moderate |
High for MACE (pioglitazone and sulfonylureas); Moderate for all the other clinical outcomes |
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Values Is there important uncertainty about or variability in how much people value the main outcomes? | ||
Judgment | Research evidence | Additional considerations |
No important uncertainty or variability |
No evidence of variability or uncertainty HbA1c, body weight, severe hypoglycemia, macrovascular complications, and mortality are already considered among critical outcomes of the treatment of type 2 diabetes by scientific societies23−26 |
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Balance of effects Does the balance between desirable and undesirable effects favor the intervention or the comparison? | ||
Judgment | Research evidence | Additional considerations |
Varies | The balance of effects favors metformin, GLP-1 RA and SGLT-2i over other classes of drugs, whereas it is unfavorable for sulfonylureas | |
Resources required How large are the resource requirements (costs)? | ||
Judgment | Research evidence | Additional considerations |
Varies |
Low for metformin, pioglitazone, sulfonylureas, acarbose Moderate for other classes, higher for GLP-1RA and insulin |
Some bioequivalent molecules could reduce direct costs for the most expensive approaches (i.e., insulin and GLP-1RA) |
Certainty of evidence of required resources What is the certainty of the evidence of resource requirements (costs)? | ||
Judgment | Research evidence | Additional considerations |
High | Several good-quality studies explored this issue | |
Cost-effectiveness Does the cost-effectiveness of the intervention favor the intervention or the comparison? | ||
Judgment | Research evidence | Additional considerations |
Varies | The cost-effective evaluation depends on the drug used; comprehensive network meta-analysis exploring the economic implication of the different approaches are lacking, if we consider the large availability of options | |
Equity What would be the impact on health equity? | ||
Judgment | Research evidence | Additional considerations |
Probably no impact | Drugs recommended in the present guideline are already considered as first- and second-line treatments for patients without previous cardiovascular events in the principal guidelines23−26 | |
Acceptability Is the intervention acceptable to key stakeholders? | ||
Judgment | Research evidence | Additional considerations |
Probably yes | No specific evidence is available on this issue | |
Feasibility Is the intervention feasible to implement? | ||
Judgment | Research evidence | Additional considerations |
Probably yes | A large part of patients with type 2 diabetes in Italy is already treated with metformin, whereas GLP-1 RA and SGLT-2i are still relatively underutilized and sulfonylureas still prescribed, despite being less frequently than in the last years |