Does choice of antidiabetes therapy influence macrovascular outcomes?

Despite a clear epidemiologic relationship between hemoglobin A(1c) levels and the risk of cardiovascular (CV) disease in patients with type 2 diabetes mellitus (T2DM), prospective studies examining the benefit of intensive glucose lowering in reducing CV events have yielded conflicting results. Controversy over the choice of antidiabetic therapy for lowering macrovascular events has existed for nearly four decades, beginning with the potential risk of increased CV mortality with sulfonylurea use. Although sulfonylureas were subsequently felt to be safe, a more recent controversy was raised as to whether rosiglitazone use was associated with an increased risk of CV events. Additionally, early positive results for metformin in reducing macrovascular events have not been clearly substantiated. Because a typical patient with T2DM may live 20 to 40 years with the disease, long-term prevention of CV events is very important. An evidenced-based review of choice of antidiabetic therapy to reduce CV events in T2DM is discussed below.