“Doctor, How Certain Are We That This Diabetes Medication Is Best for Me?”

Concerns about the benefits and harms of antiglycemic oral medications date back to 1970, when reports that sulfonylurea therapy was associated with increased cardiovascular risk were published (1). Although the United Kingdom Prospective Diabetes Survey resolved this controversy (2), we are in the midst of yet another debate: whether rosiglitazone, a second-generation thiazolidinedione, increases the risk for cardiovascular events (3). Given the health importance of diabetes and glycemic control in the population, uncertainty about oral antiglycemic agents affects informed decision making by millions of people in the United States and their physicians.

Evaluating oral antiglycemic agents is difficult because there are so many individual drugs and classes (4) and so much information, largely from industry-sponsored clinical trials. Physicians must cope with conflicting prescribing pressures from pharmacy benefit management programs on the one hand and direct-to-patient marketing on the other. To cut through the confusion, we desperately need objective, systematic analyses of the evidence that informs shared pharmaceutical decision making between patients and physicians.

Fortunately, the U.S. Congress directed the Agency for Healthcare Research and Quality (AHRQ), through the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003, Section 1013, to establish the Effective Health Care Program to conduct and support research with a focus on “outcomes, comparative clinical effectiveness, and appropriateness of health care items and services (including prescription drugs)” (5). Commissioned by AHRQ under the Effective Health Care Program and its Evidence-based Practice Centers (EPCs), Bolen and colleagues (6) analyzed 216 studies of oral antiglycemic agents; they report their findings in this issue. They concluded that, compared with newer, more expensive agents (thiazolidinediones, α-glucosidase inhibitors, and meglitinides), older agents (second-generation sulfonylureas and metformin) have similar or superior effects on glycemic control, lipids, and other intermediate end points. They also concluded that the evidence from …