Editorial opinion

Urinary albumin excretion with sitagliptin compared to sulfonylurea as add on to metformin in type 2 diabetes patients with albuminuria: a real-world evidence study

This ‘real-world’ study compares the reduction in microalbuminuria (assessed by urine albumin:creatinine ratio [UACR]) seen when adding a gliptin to background metformin therapy, versus that with a sulphonylurea. The conclusion is that both therapies reduce UACR but the gliptin (in this case, sitagliptin) is more efficacious.

There are several health-warnings that need to be applied to this study. It is small (N=564 patients), patients were followed for a very short period (mean of nine months) and the result was a ‘trend’. Furthermore, elevated UACR is a highly variable marker, which needs to be repeated to be valid (in some studies, four timed urine collections have been analysed); this assessment of computerised records used only one spot-test. Moreover, whilst the diabetes community have been brain-washed into thinking that elevations in UACR mean impending dialysis, it is clear that increased UACR can be a result of multiple pathologies and that end-stage renal disease is a highly unlikely outcome for the vast majority of patients with diabetes. This is probably the reason for it dropping off the QoF agenda, although the implication was that it has now become so embedded in GP psychology that it will continue to be assessed without compensation. I doubt that this will prove to be the case, nor do I think that it should be, given that widespread screening for an elevated UACR has ever been justified.

I would suggest that regarding microalbuminuria, appropriate blood pressure control should be the focus rather than UACR and that for gliptins and SUs, HbA1c reduction, hypoglycaemia and weight are the outcomes that should guide choices….

Professor Steve Bain