Advertisements for Januvia

A full-page advertisement by Merck in the July 11, 2014 New York Times urges adults with type 2 diabetes to talk to their doctors about Januvia (sitagliptin). Since we published an article on Drugs for Diabetes fairly recently (March 1, 2014), I thought a comparison between Merck’s advice and ours might be interesting.

The advertisement pictures a woman sitting on one end of a seesaw telling her (not pictured) seesaw mate that Januvia works when her blood sugar is high and works less when her blood sugar is low. That seems fair because DPP-4 inhibitors like sitagliptin potentiate glucose-dependent secretion of insulin and suppress secretion of glucagon. The ad goes on to say that Januvia, along with diet and exercise, helps lower blood sugar in adults with type 2 diabetes. That’s true too, but the ad does not say, as we did in our article, that DPP-4 inhibitors like sitagliptin lower glycosylated hemoglobin (A1C) less than metformin, sulfonylureas, thiazolidinediones, or GLP-1 receptor agonists.

Januvia is a prescription pill you take once a day, the ad emphasizes with red print instead of my italics. That is true too, but the implication that other antidiabetic drugs must be taken more often is somewhat misleading, because sulfonylureas, thiazolidinediones, some formulations of metformin, and other DPP-4 inhibitors are also taken once a day.

The ad does a good job of describing the side effects of Januvia, warning about allergic reactions and the possibility of pancreatitis. The advantages of DPP-4 inhibitors over some other antidiabetic drugs actually are the side effects they do not cause: they do not cause weight gain and rarely cause hypoglycemia. As you might expect, the ad describes those advantages in headlines, which is fair enough. We would not expect Merck to add that SGLT-2 inhibitors cause weight loss and have an incidence of hypoglycemia comparable to that of placebo. You would see that, of course, in our Drugs for Diabetes article.

All in all, then, the advertisement for Januvia, if we must have drug ads directed at patients, does a decent job of describing the drug. What it lacks is perspective. Patients who read the ad would have no idea that sitagliptin is a second-line drug at best. The advertisement does not tell them, as we do, that in the absence of contraindications, metformin is the preferred first-line agent for treatment of type 2 diabetes, and if metformin does not achieve the desired goal, then a sulfonylurea, a GLP-1 receptor agonist, or possibly a DPP-4 inhibitor could be added. And it does not say, as we do, that the long-term safety of DPP-4 inhibitors is still unknown. But patients really don’t need to know any of that, as long as their doctors read The Medical Letter.

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  1. Michael Makover, MD says:

    It is puzzling that you list sulfonylureas as second-line drugs. There is little evidence that they prevent complications from diabetes, much evidence that they might increase heart risk and certainly are the major cause of serious hypoglycemia among oral medications. Many of us feel that they should be reserved as fourth line drugs at best.

  2. James Houle MD FP says:

    The quoted incidence of hypoglycemia with sulfonylureas according to Invokana is around 30% but serious hypoglycemia is 0.3% and carefully counseling patients helps minimize this risk. In 30 years treating a large number of diabetics I can remember 4 patients who required ER attention and they had mild dementia. My understanding is that glyburide is the only one that has clear evidence of CAD and should be avoided. The cost effectiveness clearly supports their use.

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