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A Systematic Review

Elizabeth Selvin, PhD, MPH; Shari Bolen, MD, MPH; Hsin-Chieh Yeh, PhD; Crystal Wiley, MD, MPH; Lisa M. Wilson, ScM; Spyridon S. Marinopoulos, MD, MBA; Leonard Feldman, MD; Jason Vassy, MD, MPH; Renee Wilson, MS; Eric B. Bass, MD, MPH; Frederick L. Brancati, MD, MHS

Arch Intern Med. 2008;168(19):2070-2080.

Background  A wide variety of oral diabetes medications are currently available for the treatment of type 2 diabetes mellitus, but it is unclear how these agents compare with respect to long-term cardiovascular risk. Our objective was to systematically examine the peer-reviewed literature on the cardiovascular risk associated with oral agents (second-generation sulfonylureas, biguanides, thiazolidinediones, and meglitinides) for treating adults with type 2 diabetes.

Methods  We searched MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials, from inception through January 19, 2006. Forty publications of controlled trials that reported information on cardiovascular events (primarily myocardial infarction and stroke) met our inclusion criteria. Using standardized protocols, 2 reviewers serially abstracted data from each article. Trials were first described qualitatively. For comparisons with 4 or more independent trials, results were pooled quantitatively using the Mantel-Haenszel method. Results are presented as odds ratios (ORs) and corresponding 95% confidence intervals (CIs).

Results  Treatment with metformin hydrochloride was associated with a decreased risk of cardiovascular mortality (pooled OR, 0.74; 95% CI, 0.62-0.89) compared with any other oral diabetes agent or placebo; the results for cardiovascular morbidity and all-cause mortality were similar but not statistically significant. No other significant associations of oral diabetes agents with fatal or nonfatal cardiovascular disease or all-cause mortality were observed. When compared with any other agent or placebo, rosiglitazone was the only diabetes agent associated with an increased risk of cardiovascular morbidity or mortality, but this result was not statistically significant (OR, 1.68; 95% CI, 0.92-3.06).

Conclusions  Meta-analysis suggested that, compared with other oral diabetes agents and placebo, metformin was moderately protective and rosiglitazone possibly harmful, but lack of power prohibited firmer conclusions. Larger, long-term studies taken to hard end points and better reporting of cardiovascular events in short-term studies will be required to draw firm conclusions about major clinical benefits and risks related to oral diabetes agents.

Author Affiliations: Departments of Epidemiology (Drs Selvin, Yeh, and Brancati) and Health Policy and Management (Dr Bass), Johns Hopkins Bloomberg School of Public Health, The Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions (Drs Selvin, Yeh, and Brancati), Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine (Drs Bolen, Yeh, Wiley, Marinopoulos, Feldman, Bass, and Brancati and Mss L. M. Wilson and R. Wilson), and John Hopkins Evidence-Based Practice Center, The Johns Hopkins University (Mss L. M. Wilson and R. Wilson and Dr Bass), Baltimore, Maryland; and Department of Medicine, Washington University School of Medicine, St Louis, Missouri (Dr Vassy).

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