An Evidence-Based Medicine Approach to Antihyperglycemic Therapy in Diabetes Mellitus to Overcome Overtreatment
Open accessAbstract
Overtreatment is pervasive in medicine and leads to potential patient harms and excessive costs in health care. Although evidence-based medicine is often derided as practice by rote algorithmic medicine, the appropriate application of key evidence-based medicine principles in clinical decision making is fundamental to preventing overtreatment and promoting high-value, individualized patient-centered care. Specifically, this article discusses the importance of (1) using absolute rather than relative estimates of benefits to inform treatment decisions; (2) considering the time horizon to benefit of treatments; (3) balancing potential harms and benefits; and (4) using shared decision making by physicians to incorporate the patient’s values and preferences into treatment decisions. Here, we illustrate the application of these principles to considering the decision of whether or not to recommend intensive glycemic control to patients to minimize microvascular and cardiovascular complications in type 2 diabetes mellitus. Through this lens, this example will illustrate how an evidence-based medicine approach can be used to individualize glycemic goals and prevent overtreatment, and can serve as a template for applying evidence-based medicine to inform treatment decisions for other conditions to optimize health and individualize patient care.
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SGLT2i and GLP1ra significantly reduce cardiovascular deaths independent of their effect on hyperglycemia.
“Sodium-glucose co-transporter-2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP1ra) are novel classes of medications for type 2 diabetes that significantly reduce cardiovascular deaths independent of their effect on hyperglycemia and are widely endorsed by clinical practice guidelines.4–11”
From Disparities in Use of Novel Diabetes Medications by Insurance: A Nationally Representative Cohort Study (2024) · cites this paper as [8]
In “What are the estimated benefits of intensive glycemic control in type 2 diabetes?”, the paper reports clinically significant reductions in cardiovascular mortality in trials of empagliflozin and liraglutide. It says the reductions were likely not mediated by intensive glycemic control, but treats that mechanism as an inference; the claim states independence as fact and extends findings from two drugs to their entire classes. (LLM, conf=0.87)
Experimental — accuracy not yet measuredSGLT2i and GLP1ra are widely endorsed by clinical practice guidelines.
“Sodium-glucose co-transporter-2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP1ra) are novel classes of medications for type 2 diabetes that significantly reduce cardiovascular deaths independent of their effect on hyperglycemia and are widely endorsed by clinical practice guidelines.4–11”
From Disparities in Use of Novel Diabetes Medications by Insurance: A Nationally Representative Cohort Study (2024) · cites this paper as [8]
The section on estimated treatment benefits reports cardiovascular mortality reductions with empagliflozin and liraglutide, but does not say clinical practice guidelines endorse them. The Overtreatment in Type 2 Diabetes section discusses guidelines’ glycemic goals, not recommendations for these drug classes. Searches for guideline endorsement of the drugs found no supporting passage in our copy; page numbers were unavailable. (LLM, conf=0.72)
Experimental — accuracy not yet measured
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Self-citationGould, S. J. (2013) · The AMA Journal of Ethic · doi:10.1001/virtualmentor.2013.15.1.mnar1-1301 · Cited by 19 · see citing works
Makam, A. N., Auerbach, A. D., & Steinman, M. A. (2014) · Journal of Hospital Medicine · doi:10.1002/jhm.2205 · Cited by 13 · see citing works
Self-citationMcCormack, J. P., Martin, S. A., & Newman, D. H. (2015) · Diabetes Care · doi:10.2337/dc15-0074 · Cited by 6 · see citing works
Coca, S. G., Ismail-Beigi, F., Haq, N., Krumholz, H. M., & Parikh, C. R. (2012) · Archives of Internal Medicine · doi:10.1001/archinternmed.2011.2230 · Cited by 1 · see citing works
Flagged first, then by citations
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Silbert, R., Salcido-Montenegro, A., Rodriguez-Gutierrez, R., Katabi, A., & McCoy, R. G. (2018) · Current Diabetes Reports · doi:10.1007/s11892-018-1018-0 · Cited by 229 · see citing works
Andreozzi, F., Candido, R., Corrao, S., Fornengo, R., Giancaterini, A., Ponzani, P., Ponziani, M. C., Tuccinardi, F., & Mannino, D. (2020) · Diabetology & Metabolic Syndrome · doi:10.1186/s13098-020-00559-7 · Cited by 128 · see citing works
Pérez-Belmonte, L. M., Sanz-Cánovas, J., García de Lucas, M. D., Ricci, M., Avilés-Bueno, B., Cobos-Palacios, L., Pérez-Velasco, M. A., López-Sampalo, A., Bernal-López, M. R., Jansen-Chaparro, S., et al. (2022) · Frontiers in Endocrinology · doi:10.3389/fendo.2022.851035 · Cited by 35 · see citing works
Bepo, L., Nguyen, O. K., & Makam, A. N. (2024) · Journal of General Internal Medicine · doi:10.1007/s11606-024-08961-x · Cited by 20 · see citing works
Self-citation
- Authors
- Makam, A. N., & Nguyen, O. K.
- Affiliations
- The University of Texas Southwestern Medical Center (US)
- Venue
- Circulation
- Published
- 2017-01-10
- Volume
- 135
- Issue
- 2
- Pages
- 180-195
- ISSN
- 0009-7322 (ISSN-L)
- 1524-4539
- PMC
- PMC5502688
- OpenAlex
- W2570554553
- Cited by
- 52
- References
- 96
- Citations by year
- 2026: 2 · 2025: 2 · 2024: 4 · 2023: 2 · 2022: 7 · 2021: 7 · 2020: 2 · 2019: 11 · 2018: 8 · 2017: 6
- FWCI
- 5.84
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Circulation (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- eScholarship (California Digital Library) (submittedVersion)
- Funders
- University of Texas Southwestern Medical Center
- National Institutes of Health (UL1TR001105, KL2TR001103)
- Agency for Healthcare Research and Quality (R24HS022418)
- National Institute on Aging (R03AG053291, K23AG052603)
- National Center for Advancing Translational Sciences
- Topics
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Treatment and Management
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Clinical practice guidelines implementation
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Research
- Keywords
- overtreatment, antihyperglycemic therapy, type 2 diabetes, tight glycemic control, glycemic targets, shared decision-making, benefit-harm balance, patient-centered care, high-value care, microvascular complications, cardiovascular complications
- MeSH terms
- Decision Making, Diabetes Mellitus, Humans, Hypoglycemic Agents, Patient Participation, Patient-Centered Care, Evidence-Based Medicine
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
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