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AHRQ--Agency for Healthcare Research and Quality: Advancing Excellence in Health Care

Topic Suggestion Description

View Topic Suggestion Disposition (PDF) 192 kB

Date submitted: August 30, 2009

Briefly describe a specific question, or set of related questions, about a health care test or treatment that this program should consider.
What is the best second drug choice for treatment of type 2 diabetes?
Does your question include a comparison of different health care approaches? (If no, your topic will still be considered.)
If yes, explain the specific technologies, devices, drugs, or interventions you would like to see compared:
Metformin is now established as the first line treatment of diabetes. However, much controversy exists as to what should be added when metformin fails. Sulfonylureas are commonly used due to their low cost. However, the combination of Met + SU has been associated in several studies with an increase in the risk of mortaliy.
On the other hand newer ageants have their own problems and side effects and have not been well studied.
What patients or group(s) of patients does your question apply to? (Please include specific details such as age range, gender, coexisting diagnoses, and indications for therapy.)
Patients with type 2 diabetes who were started on metformin and now have an A1c that is above goal
Are there subgroups of patients that your question might apply to? (For example, an ethnic group, stage or severity of a disease.)
Describe the health-related benefits you are interested in. (For example, improvements in patient symptoms or problems from treatment or diagnosis.)
1. Mortality
2. Cardiovascular events
3. Hospitalizations
4. Diabetes Complications
5. cost Effectiveness
Describe any health-related risks, side effects, or harms that you are concerned about.
CV events

Appropriateness for EHC Program

Does your question include a health care drug, intervention, device, or technology available (or likely to be available) in the U.S.?
Which priority area(s) and population(s) does this topic apply to? (check all that apply)
EHC Priority Conditions (updated in 2008)
  • Diabetes mellitus
AHRQ Priority Populations
  • Elderly
Federal Health Care Program
  • Medicaid
  • Medicare


Describe why this topic is important.
Type 2 diabetes is a very common problem and disproportionately affects minorities and the elderly. It is an expensive disease over the lifetime of the patient and we should determine what is the most cost effective drug combination.
What specifically motivated you to ask this question? (For example, you are developing a clinical guideline, working with a policy with large uncertainty about the appropriate approach, costly intervention, new research you have read, items in the media you may have seen, a clinical practice dilemma you know of, etc.)
1. clinical practice dilemna
2. I have extensive research experience in diabetes
3. I published a meta analysis showing and increase in hospitalization and mortality with a combination of metformin and sulfonylureas compared to monotherapy. However, I do not know how that comares with other combinations.
Does your question represent uncertainty for clinicians and/or policy-makers? (For example, variations in clinical care, controversy in what constitutes appropriate clinical care, or a policy decision.)
If yes, please explain:
There is no consensus on the best second line therapy combination for diabetes. The ADA lists several options

Potential Impact

How will an answer to your research question be used or help inform decisions for you or your group?
It will have a huge impact on treatment guidelines
Describe the timeframe in which an answer to your question is needed.
a few monthts to extract data from several databases
Describe any health disparities, inequities, or impact on vulnerable populations your question applies to.
This is an important issue for the elderly

Nominator Information

Other Information About You: (optional)
Please choose a description that best describes your role or perspective: (you may select more than one category if appropriate)
  • Physician
Are you making a suggestion as an individual or on behalf of an organization?