Flip flop

When ADOPT came out last year, it was pretty much a home run. Many practitioners were advocating changing guidelines to recommend Avandia (rosiglitazone) as initial monotherapy. I was quite vocal in my disagreement. I think metformin has more favorable effects, blah blah.

Now that rosiglitazone's safety has been seriously questioned, everyone is jumping on the 'TZD's suck' band wagon, which is dragging pioglitazone down with it. I find this very amusing because it kind of typifies the trend in US pharmaceuticals.

I could understand the arguments against Vioxx, a drug made for symptom relief and not much else. Natrecor was disappointing, but it had filled a nonexistent hole anyway. But this Avandia stuff is ridiculous. You can't tell me that optimal glycemic control does not have benefits. We have modeled ALL of glycemic therapy on this idea, that microvascular disease is the consequence of hyperglycemia.

And none of this talk answers a quite serious and obvious question about Avandia. Is Avandia doing something or not doing something? By that I mean is the risk caused by the drug itself or is the increase in heart attacks the same as untreated diabetes? If it's simply the risk of untreated diabetes, well then I'll slap some metformin on top and call it a day. But if the drug is causing heart attacks, that's a different story.

I'm willing to concede cardiovascular disease, but keep in mind that there are a lot of complications of diabetes. Choosing between them is like trading bananas for pears. Is it better to have heart disease or kidney failure? Is it better to be blind or a CHF patient?

I don't like TZD's and I've never been a big fan, but I can't argue with the fact that they work, and work well, and probably are one of the best oral diabetes medications. Since this all came out, I haven't written any scripts, and thankfully I've always preferred pioglitazone so I can at least hedge my bets until we figure out if this is a class effect. But I'd be hard-pressed to say to someone that Avandia was bad for them.