A New Drug for Type 2 Diabetes

As Americans grow ever bigger, the market for diabetes drugs grows bigger right along with them. The next issue of The Medical Letter will include an article on a new drug for type 2 diabetes, new not only to the market, but also in its mechanism of action. Canagliflozin (Invokana) prevents reabsorption of glucose in the proximal renal tubule, so glucose goes out in the urine and down in the blood. Of course patients with uncontrolled diabetes may have glycosuria to begin with, but not enough to bring their blood glucose down into an acceptable range, and not nearly as much as our brand new drug produces.

As we said in our last Treatment Guidelines article on Drugs for Diabetes, most clinicians start patients with type 2 diabetes on metformin (Glucophage, and generics). There is general agreement on that. But many patients need something else as well, and there is no general agreement on what comes after metformin, and given the huge number of patients who have type 2 diabetes and need a second drug, the commercial competition is fierce. We published an article in The Medical Letter (July 23, 2012) titled “What Comes After Metformin for Type 2 Diabetes?” There we published a table that listed all the candidate drugs with their advantages, disadvantages, and cost, and we probably will include an updated version of that table in our article on canagliflozin.

One thing that caught my eye in the package insert for canagliflozin was the broad indication approved by the FDA (“for treatment of type 2 diabetes”), ignoring the consensus agreement that you start with metformin. We just published an article on a not-quite-as-new drug for metastatic colorectal cancer with labeling that specified 4 different regimens that had to be tried before using the new drug became acceptable. Maybe package inserts will be getting thinner in the age of the sequester.

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    how much of a drop in hgA1C SHOULD WE EXPECT TO SEE

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