UKPDS 28: a randomized trial of efficacy of early addition of metformin in sulfonylurea-treated type 2 diabetes. U.K. Prospective Diabetes Study Group

Risk of fatal and nonfatal lactic acidosis with metformin use in type 2 diabetes mellitus

BACKGROUND

Metformin is an oral anti-hyperglycemic agent that has been shown to reduce total mortality compared to other anti-hyperglycemic agents, in the treatment of type 2 diabetes mellitus. Metformin, however, is thought to increase the risk of lactic acidosis, and has been considered to be contraindicated in many chronic hypoxemic conditions that may be associated with lactic acidosis, such as cardiovascular, renal, hepatic and pulmonary disease, and advancing age.

OBJECTIVES

To assess the incidence of fatal and nonfatal lactic acidosis, and to evaluate blood lactate levels, for those on metformin treatment compared to placebo or non-metformin therapies.

SEARCH STRATEGY

A comprehensive search was performed of electronic databases to identify studies of metformin treatment. The search was augmented by scanning references of identified articles, and by contacting principal investigators.

SELECTION CRITERIA

Prospective trials and observational cohort studies in patients with type 2 diabetes of least one month duration were included if they evaluated metformin, alone or in combination with other treatments, compared to placebo or any other glucose-lowering therapy.

DATA COLLECTION AND ANALYSIS

The incidence of fatal and nonfatal lactic acidosis was recorded as cases per patient-years, for metformin treatment and for non-metformin treatments. The upper limit for the true incidence of cases was calculated using Poisson statistics. In a second analysis lactate levels were measured as a net change from baseline or as mean treatment values (basal and stimulated by food or exercise) for treatment and comparison groups. The pooled results were recorded as a weighted mean difference (WMD) in mmol/L, using the fixed-effect model for continuous data.

MAIN RESULTS

Pooled data from 347 comparative trials and cohort studies revealed no cases of fatal or nonfatal lactic acidosis in 70,490 patient-years of metformin use or in 55,451 patients-years in the non-metformin group. Using Poisson statistics the upper limit for the true incidence of lactic acidosis per 100,000 patient-years was 4.3 cases in the metformin group and 5.4 cases in the non-metformin group. There was no difference in lactate levels, either as mean treatment levels or as a net change from baseline, for metformin compared to non-metformin therapies.

AUTHORS' CONCLUSIONS

There is no evidence from prospective comparative trials or from observational cohort studies that metformin is associated with an increased risk of lactic acidosis, or with increased levels of lactate, compared to other anti-hyperglycemic treatments.

Risk of fatal and nonfatal lactic acidosis with metformin use in type 2 diabetes mellitus

BACKGROUND

Metformin is an oral anti-hyperglycemic agent that has been shown to reduce total mortality compared to other anti-hyperglycemic agents, in the treatment of type 2 diabetes mellitus. Metformin, however, is thought to increase the risk of lactic acidosis, and has been considered to be contraindicated in many chronic hypoxemic conditions that may be associated with lactic acidosis, such as cardiovascular, renal, hepatic and pulmonary disease, and advancing age.

OBJECTIVES

To assess the incidence of fatal and nonfatal lactic acidosis, and to evaluate blood lactate levels, for those on metformin treatment compared to placebo or non-metformin therapies.

SEARCH STRATEGY

A comprehensive search was performed of electronic databases to identify studies of metformin treatment. The search was augmented by scanning references of identified articles, and by contacting principal investigators.

SELECTION CRITERIA

Prospective trials and observational cohort studies in patients with type 2 diabetes of least one month duration were included if they evaluated metformin, alone or in combination with other treatments, compared to placebo or any other glucose-lowering therapy.

DATA COLLECTION AND ANALYSIS

The incidence of fatal and nonfatal lactic acidosis was recorded as cases per patient-years, for metformin treatment and for non-metformin treatments. The upper limit for the true incidence of cases was calculated using Poisson statistics. In a second analysis lactate levels were measured as a net change from baseline or as mean treatment values (basal and stimulated by food or exercise) for treatment and comparison groups. The pooled results were recorded as a weighted mean difference (WMD) in mmol/L, using the fixed-effect model for continuous data.

MAIN RESULTS

Pooled data from 347 comparative trials and cohort studies revealed no cases of fatal or nonfatal lactic acidosis in 70,490 patient-years of metformin use or in 55,451 patients-years in the non-metformin group. Using Poisson statistics the upper limit for the true incidence of lactic acidosis per 100,000 patient-years was 4.3 cases in the metformin group and 5.4 cases in the non-metformin group. There was no difference in lactate levels, either as mean treatment levels or as a net change from baseline, for metformin compared to non-metformin therapies.

AUTHORS' CONCLUSIONS

There is no evidence from prospective comparative trials or from observational cohort studies that metformin is associated with an increased risk of lactic acidosis, or with increased levels of lactate, compared to other anti-hyperglycemic treatments.

The effects of metformin plus sulfonylurea therapy on clinical features of the metabolic syndrome

Introduction. Insulin resistance is a well-known leading factor in the development of metabolic syndrome. The aim of this study was to evaluate metabolic effects of metformin added to sulfonylurea in unsuccessfully treated type 2 diabetic patients with metabolic syndrome. Material and methods. A group of thirty subjects, with type 2 diabetes, secondary sulfonylurea failure and metabolic syndrome were administered the combined therapy of sulfonylurea plus metformin for six months. Metformin 2000 mg/d was added to previously used sulfonylurea agent in maximum daily dose. Antihypertensive and hypolipemic therapy was not changed. The following parameters were assessed at the beginning and after six months of therapy: glycemic control, body mass index, waist circumference, blood pressure, triglycerides, total cholesterol and its fractions, homeostatic models for evaluation of insulin resistance and secretion (HOMA R, HOMA B) and C- peptide. Results. Glycemic control was significantly improved after six months of the combined therapy: (fasting 7.89 vs. 10.61 mmol/l. p<0.01; postprandial 11.12 vs. 12.61 mmol/l. p<0.01, p<0.01; glycosylated hemoglobin 6.81 vs. 8.83%. p<0.01). the body mass index and waist circumference were significantly lower (26.7 vs. 27.8 kg/m2, p<0.01 and 99.7 vs. 101.4 cm for men, p<0.01; 87.2 vs. 88.5 for women, p<0.01). Fasting plasma triglycerides decreased from 3.37 to 2.45 mmol/l (p<0.001) and HOMA R from 7.04 to 5.23 (p<0.001). No treatment effects were observed on blood pressure, cholesterol, and residual insulin secretion. Conclusion. Administration of metformin in type 2 diabetes with metabolic syndrome decreased cardiovascular risk factors by reducing glycemia, triglycerides, BMI, central obesity and insulin resistance.

Diabetes medications and body weight

Tight diabetes control sometimes comes with a price: weight gain and hypoglycemia. Two of the three major recent trials that looked at the relationship between intensive diabetes control and cardiovascular events reported significant weight gain among the intensively treated groups. There is a growing concern that the weight gain induced by most diabetes medications diminishes their clinical benefits. On the other hand, there is a claim that treating diabetes with medications that are weight neutral or induces weight loss or less weight gain while minimizing those that increase body weight may emerge as the future direction for treating overweight and obese patients with diabetes. This review clarifies the weight effect of each of the currently available diabetes medications, and explains the mechanism of action behind this effect. Despite the great variability among reviewed clinical trials, the currently available evidence is quite sufficient to demonstrate the change in body weight in association with most of the currently available medications. This review also provides some guidelines on using diabetes medications during weight management programs.

Long-term glycaemic effects of pioglitazone compared with placebo as add-on treatment to metformin or sulphonylurea monotherapy in PROactive (PROactive 18)

AIMS

To assess the long-term glycaemic effects, concomitant changes in medications and initiation of permanent insulin use (defined as daily insulin use for a period of > or = 90 days or ongoing use at death/final visit) with pioglitazone vs. placebo in diabetic patients receiving metformin or sulphonylurea monotherapy at baseline in the PROspective pioglitAzone Clinical Trial in macroVascular Events (PROactive).

METHODS

In PROactive, patients with Type 2 diabetes and macrovascular disease were randomized to pioglitazone (force titrated to 45 mg/day) or placebo, in addition to other existing glucose-lowering therapies. In a post-hoc analysis, we categorized patients not receiving insulin at baseline and treated by oral monotherapy into two main cohorts: add-on to metformin alone (n = 514) and sulphonylurea alone (n = 1001). The follow-up averaged 34.5 months.

RESULTS

There were significantly greater reductions in glycated haemoglobin (HbA(1c)) with pioglitazone than with placebo and more pioglitazone-treated patients achieved HbA(1c) targets, irrespective of the baseline oral glucose-lowering regimen and despite a decrease in the use of other glucose-lowering agents. Approximately twice as many in the placebo groups progressed to permanent insulin use than in the pioglitazone groups across the two cohorts: 3.4% for pioglitazone and 6.5% for placebo when added to metformin monotherapy and 6.3% and 14.8%, respectively, when added to sulphonylurea monotherapy. The overall safety of both dual therapies was good.

CONCLUSIONS

Intensifying an existing oral monotherapy regimen to a dual oral regimen by adding pioglitazone resulted in sustained improvements in glycaemic control and reduced progression to insulin therapy. The efficacy and safety of adding pioglitazone to either metformin monotherapy or sulphonylurea monotherapy were good.

Ten putative contributors to the obesity epidemic

The obesity epidemic is a global issue and shows no signs of abating, while the cause of this epidemic remains unclear. Marketing practices of energy-dense foods and institutionally-driven declines in physical activity are the alleged perpetrators for the epidemic, despite a lack of solid evidence to demonstrate their causal role. While both may contribute to obesity, we call attention to their unquestioned dominance in program funding and public efforts to reduce obesity, and propose several alternative putative contributors that would benefit from equal consideration and attention. Evidence for microorganisms, epigenetics, increasing maternal age, greater fecundity among people with higher adiposity, assortative mating, sleep debt, endocrine disruptors, pharmaceutical iatrogenesis, reduction in variability of ambient temperatures, and intrauterine and intergenerational effects as contributing factors to the obesity epidemic are reviewed herein. While the evidence is strong for some contributors such as pharmaceutical-induced weight gain, it is still emerging for other reviewed factors. Considering the role of such putative etiological factors of obesity may lead to comprehensive, cause specific, and effective strategies for prevention and treatment of this global epidemic.

Efficacy of glimepiride/metformin combination versus glibenclamide/metformin in patients with uncontrolled type 2 diabetes mellitus

AIM

The aim of this study was to compare the efficacy of glimepiride/metformin combination versus glibenclamide/metformin for reaching glycemic control in patients with uncontrolled type 2 diabetes mellitus.

PATIENTS AND METHODS

A randomized, double-blind, multicenter clinical trial was performed in 152 uncontrolled type 2 diabetic patients. Serum fasting and postprandial glucose, hemoglobin A1c (A1C), high-density lipoprotein cholesterol, and triglycerides were measured. After random allocation, all patients received two pills of glimepiride (1 mg)/metformin (500 mg) or glibenclamide (5 mg)/metformin (500 mg) po once a day. Dosage was increased to a maximum of four pills in order to reach the glycemic control goals (fasting glucose <or=7.2 mmol/l, postprandial glucose <10.0 mmol/l, A1C <7%, or an A1C >or=1% reduction). Statistical analyses were carried out using chi-square, ANOVA, or Student's t test. The protocol was approved by an ethics committee and met all requirements needed to perform research in human subjects; all patients gave written informed consent.

RESULTS

Each study group included 76 patients. No significant differences in basal clinical and laboratory characteristics between groups were found. At the end of the study, A1C concentration was significantly lower in the glimepiride/metformin group (P=.025). A higher proportion of patients from the glimepiride group (44.6% vs. 26.8%, P<.05) reached the goal of A1C <7% at 12 months of treatment. A higher proportion of hypoglycemic events were observed in the glibenclamide group (28.9% vs. 17.1%, P<.047).

CONCLUSION

Glimepiride/metformin demonstrated being more efficacious than glibenclamide/metformin at reaching the glycemic control goals with less hypoglycemic events in patients with uncontrolled type 2 diabetes mellitus.

Long-term glycaemic control with metformin-sulphonylurea-pioglitazone triple therapy in PROactive (PROactive 17)

AIMS

We assessed the long-term glycaemic effects and the safety profile of triple therapy with the addition of pioglitazone vs. placebo in patients with Type 2 diabetes treated with combined metformin-sulphonylurea therapy in the PROspective pioglitAzone Clinical Trial In macroVascular Events (PROactive).

METHODS

In a post-hoc analysis, we identified patients treated with metformin plus sulphonylurea combination therapy and not receiving insulin at baseline (n = 1314). In those patients, we compared the effects of pioglitazone (force-titrated to 45 mg/day, n = 654) vs. placebo (n = 660) on glycated haemoglobin (HbA(1c)) reduction, concomitant changes in medications and initiation of permanent insulin use (defined as daily insulin use for a period of > or = 90 days or ongoing use at death/final visit).

RESULTS

Significantly greater reductions in HbA(1c) and greater proportions of patients with HbA(1c) at target were noted with pioglitazone vs, placebo, despite a decrease in the use of other oral glucose-lowering agents. There was an approximate twofold increase in progression to permanent insulin use in the placebo group vs. the pioglitazone group: 31.1 vs. 16.1%, respectively, when added to combination therapy. The overall safety of the metformin-sulphonylurea-pioglitazone triple therapy was good.

CONCLUSIONS

Intensifying an existing dual oral therapy regimen to a triple oral regimen by adding pioglitazone to the classical metformin-sulphonylurea combination resulted in sustained improvements in glycaemic control and reduced progression to insulin therapy. The advantages and disadvantages of adding pioglitazone instead of adding basal insulin should be assessed further.

Earlier triple therapy with pioglitazone in patients with type 2 diabetes

AIMS

This study assessed the efficacy of add-on pioglitazone vs. placebo in patients with type 2 diabetes uncontrolled by metformin and a sulphonylurea or a glinide.

METHODS

This multicentre, double-blind, parallel-group study randomized 299 patients with type 2 diabetes to receive 30 mg/day pioglitazone or placebo for 3 months. After this time, patients continued with pioglitazone, either 30 mg [if glycated haemoglobin A1c (HbA(1c)) <or=6.5%] or titrated up to 45 mg (if HbA(1c) >6.5%), or placebo for a further 4 months. The primary efficacy end-point was improvement in HbA(1c) (per cent change). Secondary end-points included changes in fasting plasma glucose (FPG), insulin, C-peptide, proinsulin and lipids. The proinsulin/insulin ratio and homeostasis model assessment of insulin resistance (HOMA-IR) and homeostasis model assessment of beta-cell function (HOMA-B) were calculated.

RESULTS

Pioglitazone add-on therapy to failing metformin and sulphonylurea or glinide combination therapy showed statistically more significant glycaemic control than placebo addition. The between-group difference after 7 months of triple therapy was 1.18% in HbA(1c) and -2.56 mmol/l for FPG (p < 0.001). Almost half (44.4%) of the patients in the pioglitazone group who had a baseline HbA(1c) level of <8.5% achieved the HbA(1c) target of < 7.0% by final visit compared with 4.9% in the placebo group. When the baseline HbA(1c) level was >or= 8.5%, 13% achieved the HbA(1c) target of < 7.0% in the pioglitazone group and none in the placebo group. HOMA-IR, insulin, proinsulin and C-peptide decreased and HOMA-B increased in the pioglitazone group relative to the placebo group.

CONCLUSIONS

In patients who were not well controlled with dual combination therapy, the early addition of pioglitazone improved HbA(1c), FPG and surrogate measures of beta-cell function. Patients were more likely to reach target HbA(1c) levels (< 7.0%) with pioglitazone treatment if their baseline HbA(1c) levels were < 8.5%, highlighting the importance of early triple therapy.

Pleiotropic effects of thiazolidinediones on traditional and non-traditional atherosclerotic risk factors

BACKGROUND

The thiazolidinediones pioglitazone and rosiglitazone have established efficacy in improving insulin sensitivity, glycaemic control, dyslipidaemia, hypertension and microalbuminuria in patients with type 2 diabetes. As specific agonists of peroxisome proliferator-activated receptor-gamma, thiazolidinediones have also demonstrated protective effects on a variety of atherosclerosis biomarkers and surrogate measures of cardiovascular disease.

AIM

This paper reviews the evidence for pleiotropic effects on a variety of non-traditional atherosclerotic risk factors.

DISCUSSION

Thiazolidinediones attenuate circulating levels of pro-inflammatory mediators in patients with type 2 diabetes, including C-reactive protein, interleukin-6, CD40L, monocyte chemoattractant protein-1 and metalloproteinase-9. These agents also increase levels of the vascular protective adipokine, adiponectin. The clinical significance of these findings is supported by evidence of improved endothelial dysfunction, reduced carotid intima media thickness and improvements in stenosis following coronary artery stent implantation in patients treated with thiazolidinediones. Limited data suggest that thiazolidinediones might also improve the circulating levels and functional activity of angiogenic endothelial progenitor cells, which independently predict the incidence of cardiovascular events and death. It should be noted that the US Food and Drug Administration and the European Medicines Agency have requested changes to the prescribing information for rosiglitazone to highlight the possibility of an increased risk with this agent in patients with ischaemic heart disease; on review, no such amendment was required for the pioglitazone prescribing information. Both agencies continue to suggest that the benefits of both thiazolidinediones outweight any possible detrimental effects. Further research remains to be conducted to elucidate the potentially differential vascular protective effects of thiazolidinediones. In the US, there are black box heart failure warnings for both agents.

CONCLUSION

In light of the established importance of reducing cardiovascular risk in patients with type 2 diabetes, current evidence continues to support the use of pioglitazone within multifactorial risk management strategies.

DreamTel; Diabetes risk evaluation and management tele-monitoring study protocol

BACKGROUND

The rising prevalence of type 2 diabetes underlines the importance of secondary strategies for the prevention of target organ damage. While access to diabetes education centers and diabetes intensification management has been shown to improve blood glucose control, these services are not available to all that require them, particularly in rural and northern areas. The provision of these services through the Home Care team is an advance that can overcome these barriers. Transfer of blood glucose data electronically from the home to the health care provider may improve diabetes management.

METHODS AND DESIGN

The study population will consist of patients with type 2 diabetes with uncontrolled A1c levels living on reserve in the Battlefords region of Saskatchewan, Canada. This pilot study will take place over three phases. In the first phase over three months the impact of the introduction of the Bluetooth enabled glucose monitor will be assessed. In the second phase over three months, the development of guidelines based treatment algorithms for diabetes intensification will be completed. In the third phase lasting 18 months, study subjects will have diabetes intensification according to the algorithms developed.

DISCUSSION

The first phase will determine if the use of the Bluetooth enabled blood glucose devices which can transmit results electronically will lead to changes in A1c levels. It will also determine the feasibility of recruiting subjects to use this technology. The rest of the Diabetes Risk Evaluation and Management Tele-monitoring (DreamTel) study will determine if the delivery of a diabetes intensification management program by the Home Care team supported by the Bluetooth enabled glucose meters leads to improvements in diabetes management.

TRIAL REGISTRATION

Protocol NCT00325624.

[Endothelial dysfunction in type 1 diabetes]

Vascular complications are the main cause of mortality and morbidity in diabetes. Mechanisms involved in the development of micro and macrovascular disease are complex and partially understood, but invariably begin as a dysfunctional endothelium. Nitric oxide is an important regulator of endothelial function and the impairment of its activity is determinant of the endothelial dysfunction. In type 1 diabetes, many factors like acute, chronic and post-prandial hyperglycemia, as well as the duration of diabetes or autonomic neuropathy and microalbuminuria are associated to endothelial dysfunction. Oxidative stress, polyol pathway activation, protein kinase C activation and the presence of advanced glycation end-products are potential mechanisms involved in the development of endothelial dysfunction. Early detection of endothelial dysfunction has prognostic value for the development of vascular complications and may be important in strategies for primary prevention of cardiovascular endpoints in type 1 diabetes.

Patient adherence and reimbursement amount for antidiabetic fixed-dose combination products compared with dual therapy among Texas Medicaid recipients

BACKGROUND

Little is known about the potential for improved adherence with and cost savings of fixed-dose combination therapy (FDCT) products compared with analogous dual therapy for type 2 diabetes mellitus.

OBJECTIVES

The objectives of this study were as follows: (1) to describe patient adherence to various oral antidiabetic regimens (ie, dual therapy and FDCT); (2) to determine whether there is a difference in medication adherence between FDCT users and analogous dual-therapy users; and (3) to assess whether there is a difference in reimbursement amounts between an FDCT product and its individual components.

METHODS

This study was a retrospective cohort analysis using the Texas Medicaid prescription claims database. The study subjects included those who used antidiabetic FDCT or dual therapy from August 1, 2000, to July 31, 2004. The identification period of study subjects was between August 1, 2000, and July 31, 2004, including 12 months before and after the index date, so that the overall time frame was from August 1, 1999, through July 31, 2005. Prescription claims were analyzed over a 12-month preindex and 12-month postindex period. Adherence was measured using medication possession ratio (MPR), and regimen costs per tablet were assessed utilizing the index prescription.

RESULTS

Overall, 7570 FDCT users and 14,762 dual-therapy users were identified. Regarding the postindex period, FDCT users had 1.8% higher MPR compared with dual-therapy users (78.6% vs 77.2%). Patients who switched from monotherapy to FDCT had a 1.5% decrease in adherence (from 79.7% to 78.5%), whereas those who switched from monotherapy to dual therapy had a 10.0% decrease in adherence (from 83.0% to 74.7%). Those who switched from dual therapy to FDCT had a 12.4% increase in adherence (from 72.7% to 81.7%). Multivariate logistic regression analyses revealed that among preindex monotherapy users, FDCT users were significantly more likely to have higher adherence than dual-therapy users (odds ratio [OR] = 1.867; 95% CI, 1.716-2.032) after controlling for covariates, and the results were similar among preindex dual-therapy users (OR = 1.551; 95% CI, 1.204-1.999). From the perspective of the third-party payer, all FDCT products were significantly less expensive than their equivalent individual components (P < 0.001).

CONCLUSIONS

Among these Texas Medicaid beneficiaries, antidiabetic FDCT users were more adherent to their regimen than dual-therapy users, and FDCT was less expensive than the analogous dual therapy. Because multiple agents are often required to achieve adequate glycemic control, it may be clinically and economically beneficial to treat eligible patients with FDCT products.

Therapeutic interventions and oxidative stress in diabetes

Many therapeutic agents that are used in patients with diabetes mitigate oxidative stress. These agents are of particular interest because oxidative stress is elevated in diabetes and is thought to contribute to vascular dysfunction. Agents that merely quench already formed reactive oxygen species have demonstrated limited success in improving cardiovascular outcomes. Thus, although vitamin E, C, and alpha lipoic acid appeared promising in animal models and initial human studies, subsequent larger trials have failed to demonstrate improvement in cardiovascular outcomes. Drugs that limit the production of oxidative stress are more successful in improving vascular outcomes in patients with diabetes. Thus, although statins, ACE inhibitors, ARBs and thiazolinediones are used for varied clinical purposes, their increased efficacy in improving cardiovascular outcomes is likely related to their success in reducing the production of reactive oxygen species at an earlier part of the cascade, thereby more effectively decreasing the oxidative stress burden. In particular, statins and ACE inhibitors/ ARBs appear the most successful at reducing oxidative stress and vascular disease and have potential for synergistic effects.

General practitioners trained in motivational interviewing can positively affect the attitude to behaviour change in people with type 2 diabetes. One year follow-up of an RCT, ADDITION Denmark

OBJECTIVE

To examine whether training GPs in motivational interviewing (MI) can improve type 2 diabetic patients' (1) understanding of diabetes, (2) beliefs regarding prevention and treatment, and (3) motivation for behaviour change.

METHODS

A randomized controlled trial including 65 GPs and 265 type 2 diabetic patients. The GPs were randomized in two groups, one with and one without MI training. Both groups received training in target-driven intensive treatment of type 2 diabetic patients. The intervention was a 1(1/2)-day residential course in MI with (1/2)-day follow-up twice during the first year. The patient data stemmed from previously validated questionnaires.

MAIN OUTCOME MEASURES

The Health Care Climates Questionnaire assesses the patient-doctor relationship and type of counselling. The Treatment Self-Regulation Questionnaire assesses the degree to which behaviour tends to be self-determined. The Diabetes Illness Representation Questionnaire assesses beliefs and understanding of type 2 diabetes. The Summary of Diabetes Self Care Activities assesses the extent of various self-care activities related to type 2 diabetes.

RESULTS

The response rate to our questionnaires was 87%. Patients in the intervention group were significantly more autonomous and motivated in their inclination to change behaviour after one year compared with the patients from the control group. Patients in the intervention group were also significantly more conscious of the importance of controlling their diabetes, and had a significantly better understanding of the possibility of preventing complications.

CONCLUSION

MI improved type 2 patients' understanding of diabetes, their beliefs regarding treatment aspects, their contemplation on and motivation for behaviour change. Whether our results can be sustained long term and are clinically relevant in terms of changes in risk profile advocates further research.

Impact of therapeutic advances on hypoglycaemia in type 2 diabetes

Patients with type 2 diabetes experience hypoglycaemia less frequently than those with type 1 diabetes. Some protection against hypoglycaemia is afforded by the relatively intact glucose counter-regulatory pathways that characterize the pathophysiology of early type 2 diabetes. To some extent, this protection explains why hypoglycaemic episodes in intensively treated individuals with type 2 diabetes, when they occur, are rarely severe. As diabetes progresses and therapy intensifies to achieve recommended glycaemic goals, hypoglycaemia frequency and severity increase. Thus, when it comes to instituting intensive therapy, fear of hypoglycaemia may contribute to health-care providers' 'clinical inertia'. Because maintaining glycaemic control is so important to both public and individual health, many new therapies and technologies have been developed. This manuscript reviews and considers whether these advancements in therapy make glycaemic goals easier to achieve by minimizing hypoglycaemia. Putting the hypoglycaemia experienced by type 2 diabetes patients into appropriate clinical perspective, the impact of recent progress made in pharmacotherapy, drug delivery systems, and BG monitoring on hypoglycaemia incidence is largely positive. The extent to which this progress can effect improvement over traditional therapies will, however, depend upon patient (and provider) education, motivation and behaviour change.

Once-daily basal insulin glargine versus thrice-daily prandial insulin lispro in people with type 2 diabetes on oral hypoglycaemic agents (APOLLO): an open randomised controlled trial

BACKGROUND

As type 2 diabetes mellitus progresses, oral hypoglycaemic agents often fail to maintain blood glucose control and insulin is needed. We investigated whether the addition of once-daily insulin glargine is non-inferior to three-times daily prandial insulin lispro in overall glycaemic control in adults with inadequately controlled type 2 diabetes mellitus taking oral hypoglycaemic agents.

METHODS

In the 44-week, parallel, open study that was undertaken in 69 study sites across Europe and Australia, 418 patients with type 2 diabetes mellitus that was inadequately controlled by oral hypoglycaemic agents were randomly assigned to either insulin glargine taken once daily at the same time every day or to insulin lispro administered three times per day. The primary objective was to compare the change in haemoglobin A(1c) from baseline to endpoint (week 44) between the two regimens. Randomisation was done with a central randomisation service. Analysis was per protocol. This study is registered with ClinicalTrials.gov, number NCT00311818.

FINDINGS

205 patients were randomly assigned to insulin glargine and 210 to insulin lispro. Mean haemoglobin A(1c) decrease in the insulin glargine group was -1.7% (from 8.7% [SD 1.0] to 7.0% [0.7]) and -1.9% in the insulin lispro group (from 8.7% [1.0] to 6.8% [0.9]), which was within the predefined limit of 0.4% for non-inferiority (difference=0.157; 95% Cl -0.008 to 0.322). 106 (57%) patients reached haemoglobin A(1c) of 7% or less in the glargine group and 131 (69%) in the lispro group. In the glargine group, the fall in mean fasting blood glucose (-4.3 [SD 2.3] mmol/L vs -1.8 [2.3] mmol/L; p<0.0001) and nocturnal blood glucose (-3.3 [2.8] mmol/L vs -2.6 [2.9] mmol/L; p=0.0041) was better than it was in the insulin lispro group, whereas insulin lispro better controlled postprandial blood glucose throughout the day (p<0.0001). The incidence of hypoglycaemic events was less with insulin glargine than with lispro (5.2 [95% CI 1.9-8.9] vs 24.0 [21-28] events per patient per year; p<0.0001). Respective mean weight gains were 3.01 (SD 4.33) kg and 3.54 (4.48) kg. The improvement of treatment satisfaction was greater for insulin glargine than for insulin lispro (mean difference 3.13; 95% CI 2.04-4.22).

INTERPRETATION

A therapeutic regimen involving the addition of either basal or prandial insulin analogue is equally effective in lowering haemoglobin A(1c). We conclude that insulin glargine provides a simple and effective option that is more satisfactory to patients than is lispro for early initiation of insulin therapy, since it was associated with a lower risk of hypoglycaemia, fewer injections, less blood glucose self monitoring, and greater patient satisfaction than was insulin lispro.

FUNDING

Sanofi-Aventis.

Metabolic effects of two years of exenatide treatment on diabetes, obesity, and hepatic biomarkers in patients with type 2 diabetes: an interim analysis of data from the open-label, uncontrolled extension of three double-blind, placebo-controlled trials

BACKGROUND

Exenatide, an incretin mimetic for adjunctive treatment of type 2 diabetes mellitus (T2DM), reduced glycosylated hemoglobin (HbA(1c)) and weight in 30-week placebo-controlled trials. Some patients were followed up in open-label extensions to provide 'real-world' exenatide clinical experience.

OBJECTIVE

The purpose of this study was to examine the metabolic effects of 2 years of exenatide treatment in patients with T2DM.

METHODS

For this interim analysis, data were pooled from patients who completed 1 of three 30-week, multicenter, double-blind, placebo-controlled trials and their open-label extensions. In the initial trials, subjects were randomized to BID 5-microg exenatide, 10-microg exenatide, or placebo for 30 weeks. All subjects who enrolled in the extension phase then received 5-pg exenatide BID for 4 weeks, followed by open-label treatment with 10-pg exenatide BID. Subjects continued their existing metformin and/or sulfonylurea regimens. Analyses were conducted on data from all subjects who had the opportunity to achieve 2 years of exenatide exposure, irrespective of their treatment arm in the 30-week placebo-controlled trials.

RESULTS

A total of 974 patients entered the open-label, extension phase of the trial. Two hundred eighty-three subjects (mean [SD] age, 57 [10] years; mean [SD] weight, 100[19] kg; sex, 63% male; mean [SD] body mass index, 34 [6] kg/m(2); mean [SD] HbA(1c), 8.3% [1.0%]) completed 2 years of exenatide treatment. Reductions in mean (SE) HbA(1c) from baseline to week 30 (-0.9% [0.1%]) were sustained through 2 years (-1.1% [0.1%]; P < 0.05 vs baseline), with 50% of the population achieving HbA(1c) < or = 7%. At week 30, exenatide was associated with a significant reduction in mean (SD) body weight from baseline (-2.1 [0.2] kg), with progressive reductions after 2 years (-4.7 [0.3] kg; P < 0.001 vs baseline). Patients with normal baseline alanine aminotransferase (ALT) (132/283 [47%]; normal: female < or =19 IU/L; male < or =30 IU/L) had no significant ALT change. However, patients with elevated ALT at baseline (151/283 [53%]) had a mean (SEM) reduction of ALT (-11 [1] IU/L from baseline 38 [1] IU/1; P < 0.05) and 39% achieved normal ALT by week 104. Patients with elevated ALT at baseline lost significantly more weight than patients with normal ALT at baseline (P = 0.04). However, weight change was minimally correlated with baseline ALT (r = -0.09) or ALT change (r = 0.31). Also, homeostasis model assessment of the beta-cell function (HOMA-B), blood pressure, and aspartate aminotransferase (AST) all improved. The most frequently reported adverse event was mild-to-moderate nausea.

CONCLUSIONS

In these patients with T2DM, adjunctive exenatide treatment for 2 years was generally well tolerated and resulted in a sustained reduction of HbA(1c), progressive reduction in weight, and improvements in HOMA-B, blood pressure, and the hepatic injury biomarkers, AST and ALT.

Fixed-dose combinations improve medication compliance: a meta-analysis

BACKGROUND

Compliance with treatment is a sine qua non for successful treatment of chronic conditions like hypertension. Fixed-dose combinations are designed to simplify the medication regimen and potentially improve compliance. However the data on comparison of fixed-dose combination with free-drug regimen to improve patient's medication compliance is limited.

METHODS

We conducted a MEDLINE search of studies using the words fixed-dose combinations, compliance and/or adherence. The inclusion criteria were studies which involved fixed-dose combination versus free-drug components of the regimen given separately. Only studies which reported patient's compliance were included.

RESULTS

Of the 68 studies on fixed-dose combinations, only 9 studies fulfilled the inclusion criteria. Two studies were in patients with tuberculosis, 4 in the hypertensive population, 1 in patients with human immunodeficiency virus (HIV) disease and 2 in the diabetic population. A total of 11,925 patients on fixed-dose combination were compared against 8317 patients on free-drug component regimen. Fixed-dose combination resulted in a 26% decrease in the risk of non-compliance compared with free-drug component regimen (pooled relative risk [RR] 0.74; 95% confidence interval [CI], 0.69-0.80; P <.0001). There was no evidence of heterogeneity in this analysis (chi(2)=14.49, df=8; P=.07). A subgroup analysis of the 4 studies on hypertension showed that fixed-dose combination (pooled RR 0.76; 95% CI, 0.71-0.81; P <.0001) decreased the risk of medication non-compliance by 24% compared with free-drug combination regimen.

CONCLUSIONS

Fixed-dose combination decreases the risk of medication non-compliance and should be considered in patients with chronic conditions like hypertension for improving medication compliance which can translate into better clinical outcomes.

Nateglinide or gliclazide in combination with metformin for treatment of patients with type 2 diabetes mellitus inadequately controlled on maximum doses of metformin alone: 1-year trial results

AIM

To compare long-term efficacy and safety of nateglinide plus metformin with those of gliclazide plus metformin in patients with type 2 diabetes not adequately controlled with metformin monotherapy.

METHODS

Double-blind, double-dummy, multicentre study extended to a total of 52 weeks. Patients with inadequate glucose control on maximal doses of metformin were randomized to nateglinide (N = 133) or gliclazide (N = 129) add-on treatment. After the initial 6-month study, the majority of patients in the nateglinide group [n = 112 (93.3%)] and in the gliclazide group [n = 101 (92.7%)] entered a 6-month, double-blind, extension study.

RESULTS

There was no significant difference between treatment regimens in haemoglobin Alc (HbA1c) change from baseline to 52 weeks (-0.14% for nateglinide vs. -0.27% for gliclazide; p = 0.396). Proportions of patients achieving an endpoint HbA1c of <7% were similar (40 vs. 47.4%) for nateglinide and gliclazide groups. There was no significant between-treatment difference in fasting plasma glucose change from baseline to 52 weeks (nateglinide: -0.2 mmol/l and gliclazide: -0.7 mmol/l; p = 0.096). The decreases in prandial plasma glucose area under the curve(0-4 h) from baseline were -3.26 and -1.86 h x mmol/l in the nateglinide and the gliclazide groups respectively, and the change was statistically significant in the nateglinide group only (p = 0.006). Initial insulin response to a meal was augmented with nateglinide treatment only, without between-treatment difference in 2-h insulin response. The overall rate of hypoglycaemic events was similar with nateglinide and gliclazide combinations with metformin. Nateglinide plus metformin treatment was not associated with weight gain.

CONCLUSIONS

No significant difference was seen between nateglinide plus metformin and gliclazide plus metformin in terms of HbA1c. Treatment with nateglinide plus metformin for up to 12 months was not associated with weight gain.

Pioglitazone plus glimepiride: a promising alternative in metabolic control

Current approaches to pharmacotherapy of type 2 diabetes focus on two key aspects of hyperglycaemia - insulin secretory dysfunction and insulin resistance. Combining drugs that target both these defects via different mechanisms of action improves long-term glycaemic control and offers a number of additional benefits. A fixed-dose combination of pioglitazone and glimepiride in a single tablet is now available in the US (Duetact(TM)). Both pioglitazone and glimepiride are glucose-lowering agents with distinct mechanisms of action. Pioglitazone is a potent and selective peroxisome proliferator-activated receptor-gamma agonist that improves whole-body insulin sensitivity and augments hepatic glucose uptake. On the other hand, glimepiride acts by releasing insulin from pancreatic beta-cells and improves both first and second phases of insulin secretion. These two therapies have been shown to act synergistically to treat type 2 diabetes - glimepiride therapy achieves rapid reductions in glycated haemaglobin (HbA(1c)), whereas pioglitazone sustains glycaemic control in the longer term. Furthermore, pioglitazone and glimepiride affect a number of pleiotropic markers. In particular, pioglitazone has beneficial effects on the atherogenic diabetic dyslipidaemia that are greater than those seen with rosiglitazone and other oral glucose-lowering agents. This advantage is also seen when comparing pioglitazone and rosiglitazone in combination with glimepiride. In addition, pioglitazone also improves a number of atherosclerotic risk markers that appear to translate into clinical benefits on macrovascular outcomes. Glimepiride may also improve several atherosclerotic risk markers and lipoproteins. This review discusses the potential benefits of combining pioglitazone plus glimepiride on patient compliance, targeting the dual effects of insulin resistance and beta-cell dysfunction and affecting a number of metabolic and cardiovascular parameters.

Comparison of extended-release metformin in combination with a sulfonylurea (glyburide) to sulfonylurea monotherapy in adult patients with type 2 diabetes: a multicenter, double-blind, randomized, controlled, phase III study

BACKGROUND

Metformin is widely used in the management of type 2 diabetes, either as monotherapy or in combination with other oral antihyperglycemic agents such as sulfonylureas and thiazolidinediones. Combination treatment with metformin and sulfonylurea in patients who failed monotherapy has been reported to be effective in maintaining glycemic control.

OBJECTIVE

The purpose for this study was to compare the efficacy and tolerability of extended-release metformin (MER) administered with a sulfonylurea (glyburide) to sulfonylurea monotherapy in patients with type 2 diabetes.

METHODS

This multicenter, double-blind, randomized, controlled study enrolled adult patients with type 2 diabetes who were either drug naive or previously treated with oral diabetic medications and who had not achieved glycemic control. Patients were stabilized on sulfonylurea (10 mg/d for 2 weeks, then 15 mg/d for 4 weeks) then randomly assigned at base line to receive MER (1500 mg QD, 1000 mg BID, or 2000 mg QD) plus sulfonylurea (MER+S) or sulfonylurea monotherapy for 24 weeks. Patients were evaluated every 1 to 2 weeks during sulfonylurea stabilization and initial metformin treatment, and then every 4 weeks until study end. The primary efficacy end point was glycemic control as determined by changes in glycosylated hemoglobin (HbA(1c)) from baseline to study end between those receiving combination MER+S treatment and those receiving sulfonylurea monotherapy. Adverse events (AEs) were recorded throughout the study by direct questioning, self-reporting by patients, and from the results of physical examinations and clinical laboratory tests.

RESULTS

A total of 741 patients were enrolled. Of these, 134 patients were stabilization failures, 607 patients were randomized, 575 patients received treatment and were included in the intent-to-treat population, and 417 patients completed the study per protocol. There were no significant differences between treatment groups for any demographic or baseline characteristics (all patients: mean [SD] age, 53.0 [10.6] years; male sex, 54.6% [314/575]; race, white, 58.8% [338/575], Hispanic, 28.5% [164/575]; mean [SD] weight, 97.0 [22.2] kg; obese [body mass index > or =30 kg/m(2)], 69.4% [399/575] ). There were significant decreases from baseline in mean fasting plasma glucose (FPG) levels by the end of week 1 and in mean HbA(1c) levels by week 8 in each MER+S group (both, P < 0.001). The mean (95% CI) changes from baseline to study end in the combined MER+S groups (HbA(1c), -0.74% [-0.85% to -0.64%]; FPG, -12.9 [-17.1 to -8.7] mg/dL) were significantly different from the sulfonylurea monotherapy group (HbA(1c), 0.08% [-0.08% to 0.25%]; FPG, 15.5 [8.2 to 22.8] mg/dL; P < 0.001). Among patients treated with MER+S, the mean (SEM) change in HbA(1c) was -1.26% (-1.44% to -1.07%) for drugnaive patients and -0.59% (-0.46% to 0.71%) for patients previously treated with metformin. There was a significant difference between treatment groups with regard to the prevalence of hypoglycemia (MER+S groups, 11.6% vs sulfonylurea monotherapy group, 4.2%; P = 0.007), but no significant difference was observed for gastrointestinal events. The most common gastrointestinal AEs were diarrhea and nausea (8.6% and 3.9%, respectively, in the combined MER+S groups; 2.8% and 1.4%, respectively, in the sulfonylurea monotherapy group).

CONCLUSIONS

The combination of QD or BID treatment with MER+S was significantly more effective in lowering HbA(1c) and glucose levels than sulfonylurea monotherapy in these adult patients with type 2 diabetes. However, a significant increase in the prevalence of hypoglycemia was observed in the MER+S treatment groups compared with the sulfonylurea monotherapy group.

Differential effects of oral hypoglycemic agents on glucose control and cardiovascular risk

Cardiovascular disease (CVD) burden remains the predominant cause of mortality and morbidity in the United States and in most of the developed world. The ongoing twin epidemics of obesity and type 2 diabetes mellitus provide a groundswell source for sustaining this trend for the foreseeable future (increasing the prevalence of CVD by 2-4 times), unless radical changes are made in public health policy. Oral hypoglycemic agents (OHAs) remain a mainstay for management of type 2 diabetes in most practice settings. Although these agents are primarily prescribed to achieve better glycemic control, it is important to evaluate what effects they have on cardiovascular risk and whether there are significant differences in effects among the different OHAs. This review presents the available data on the effects of the various OHAs on cardiovascular risk surrogates and actual events in retrospective and prospective study design settings.

Effect of colestimide therapy for glycemic control in type 2 diabetes mellitus with hypercholesterolemia

Colestimide is a new anion-exchange resin used to lower serum cholesterol in Japan. Because of its excellent compliance, colestimide can replace cholestyramine. To clarify the effect of colestimide on glycemic controls, colestimide (3 g/day) or pravastatin (10 mg) was given orally to patients with type 2 diabetes treated with oral hypoglycemic agents or insulin who had low-density lipoprotein (LDL) cholesterol levels exceeding 3.6 mmol/l. In the colestimide groups, fasting plasma glucose concentrations had decreased significantly from 8.5 +/- 1.4 to 7.7 +/- 1.5 mmol/l at 3 months (P<0.05), as had glycated hemoglobin (HbA1c) from 7.7 +/- 0.7% to 6.8 +/- 0.5%, for an 8% reduction (P<0.01). Fasting plasma glucose and HbA1c did not change in the pravastatin group. Total cholesterol and LDL-cholesterol decreased significantly (P<0.01) with either medication, with similar reduction rates for both drugs. Doses of oral hypoglycemic agents and insulin did not change during the study, and body weight remained stable. Considering that patients with type 2 diabetes often have hyperlipidemia, colestimide therapy may have a clinically useful dual action in such patients.

Resource use among patients with diabetes, diabetic neuropathy, or diabetes with depression

BACKGROUND

Diabetes is often associated with complications and comorbidities. The purpose of this research is to compare medical resources used by patients with the following diagnoses: diabetes mellitus (DM), diabetic neuropathy (DN), and diabetes mellitus combined with comorbid depression (DD).

METHODS

Adult patients who were diagnosed with DM, DN, or DD were included in the study. There were 55,972 patients in the DM cohort, 2,146 in the DN, and 2,379 in the DD. P values for comparisons between the three mutually exclusive cohorts were conducted using the Tukey-Kramer method. Cost comparisons among the cohorts were conducted using a stepwise multivariate regression that controlled for patient characteristics and comorbid conditions.

RESULTS

Individuals in the DM or DN cohorts were generally more likely to use antidiabetic medications than patients in the DD group. Those diagnosed with DN or DD generally used more pain medications than individuals in the DM cohort. The DM cohort had significantly lower diabetes-related total medical costs ($1,297 v $5,125, p < 0.0001) and lower total medical costs ($4,819 v $24,765, p < 0.0001) than the DN cohort. The DM cohort also had significantly lower diabetes-related total medical costs ($1,297 v $3,264, p < 0.0001) as well as significantly lower total medical costs ($4,819 v $19,298, p < 0.0001) than the DD cohort.

CONCLUSION

Results from this study indicated significant differences in demographic characteristics, comorbidities, and medication use among individuals diagnosed with DM, DN, or DD. These differences translated into significant cost differences. Patients diagnosed with DN or DD had higher diabetes-related costs than patients diagnosed with DM.

Cardiovascular risk factors associated with insulin resistance: effects of oral antidiabetic agents

Patients with type 2 diabetes mellitus have a greater risk of cardiovascular disease than nondiabetic individuals. These patients are often insulin resistant and have an associated clustering of risk factors that contribute to cardiovascular disease. The risk factors include dyslipidemia, hypertension, altered hemostasis, and chronic inflammation. A primary objective in the management of type 2 diabetes mellitus is normalization of blood glucose levels; however, some of the oral drugs used to control blood glucose levels have significant effects on these risk factors. In this article, we review the current data involving the modification of these cardiovascular risk factors by the biguanide (metformin), the thiazolidinediones (troglitazone, rosiglitazone, and pioglitazone), the alpha-glucosidase inhibitors (miglitol, acarbose), and the insulin secretagogs (glyburide [glibenclamide], glipizide, chlorpropamide, tolbutamide, tolazamide, glimepiride, repaglinide, and nateglinide). Generally, the thiazolidinediones improve hemostasis and endothelial function and reduce blood pressure, while having variable effects on dyslipidemia. Metformin improves dyslipidemia and altered hemostasis and decreases plasma C-reactive protein levels with little or no effect on blood pressure. Data on the effects of the alpha-glucosidase inhibitors and insulin secretagogs are sparse; however, these drugs appear to have little or no effect on cardiovascular risk factors.

Rationale, design, and methods for glycemic control in the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) Trial

A major therapeutic question in considering accelerated atherogenesis in patients with type 2 diabetes mellitus is whether reducing insulin resistance, as a proximal defect of a host of proatherogenic abnormalities including hyperglycemia, will be superior for decreasing mortality and coronary artery disease (CAD) risk compared with treating hyperglycemia to overcome insulin resistance with insulin-providing agents. This question is highly relevant, since earlier targeted glycemic control trials utilizing conventional glucose-lowering strategies that increase insulin levels have generally failed to reduce CAD risk despite markedly reducing microvascular risk. The Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial seeks to determine whether primarily using an insulin-sensitizing strategy for treatment of type 2 diabetes is superior when compared with primarily using an insulin-providing strategy with regard to cardiovascular outcomes. This article presents the rationale, design, and methods being used to test the glycemic control hypothesis in BARI 2D.

An open, randomized, parallel-group study to compare the efficacy and safety profile of inhaled human insulin (Exubera) with metformin as adjunctive therapy in patients with type 2 diabetes poorly controlled on a sulfonylurea

OBJECTIVE

To compare the efficacy and safety profile of adding inhaled human insulin (INH; Exubera) or metformin to sulfonylurea monotherapy in patients with poorly controlled type 2 diabetes.

RESEARCH DESIGN AND METHODS

We performed an open-label, parallel, 24-week, multicenter trial. At week -1, patients uncontrolled on sulfonylurea monotherapy were divided into two HbA(1c) (A1C) arms: > or =8 to < or =9.5% (moderately high) and >9.5 to < or =12% (very high). Patients were randomized to adjunctive premeal INH (n = 225) or metformin (n = 202). The primary efficacy end point was change in A1C from baseline.

RESULTS

In the A1C >9.5% arm, INH demonstrated a significantly greater reduction in A1C than metformin. Mean adjusted changes from baseline were -2.17 and -1.79%, respectively; between-treatment difference was -0.38% (95% CI -0.63 to -0.14, P = 0.002). In the A1C < or =9.5% arm, mean adjusted A1C changes were -1.94 and -1.87%, respectively (-0.07% [-0.33 to 0.19], P = 0.610), consistent with the noninferiority criterion. Hypoglycemia (events/subject-month) was greater in the INH (0.33) than in the metformin (0.15) group (risk ratio 2.16 [95% CI 1.67-2.78]), but there were no associated discontinuations. Other adverse events, except increased cough in the INH group, were similar. At week 24, changes in pulmonary function parameters were small and comparable between groups. Insulin antibody binding increased more with INH but did not have any associated clinical manifestations.

CONCLUSIONS

In patients with type 2 diabetes poorly controlled on a sulfonylurea (A1C >9.5%), the addition of premeal INH significantly improves glycemic control compared with adjunctive metformin and is well tolerated.

Lipids in polycystic ovary syndrome: role of hyperinsulinemia and effects of metformin

OBJECTIVE

Patients with polycystic ovary syndrome frequently suffer from hyperinsulinemia and adverse lipid profile. This study evaluated effects of metformin on lipid profile.

STUDY DESIGN

Lipid profiles in hyperinsulinemic (n = 43) and normoinsulinemic (n = 45) subjects were compared. Hyperinsulinemic subjects were treated with metformin (500 mg po tid) and lipid profiles were reevaluated at 3 and 6 months of treatment.

RESULTS

The hyperinsulinemic group had significantly lower high-density lipoprotein (HDL) (by 11%), higher total cholesterol to HDL ratio (by 23%), and greater triglycerides (by 57%) than the normoinsulinemic group. Six-month metformin therapy in hyperinsulinemic women was associated with a significant decrease of insulin level (by 35%), total cholesterol (by 11%), low-density lipoprotein (LDL) (by 12%), and triglycerides (by 33%). Levels of lipids in hyperinsulinemic women after metformin therapy were comparable to levels observed in normoinsulinemic subjects.

CONCLUSION

The present study supports the notion that metformin may be considered as a prophylactic therapy lowering cardiovascular risk factors in hyperinsulinemic women with polycystic ovary syndrome.

The place of sulfonylureas in the therapy for type 2 diabetes mellitus

Sulfonylureas are still largely used for treatment of type 2 diabetic patients, and they still occupy a central position in many international therapy guidelines. More recently concern has been raised with respect to possible adverse effects associated with the use of these agents. Sulfonylureas are, indeed, believed to favor the development of hypoglycemia, to accelerate beta cell apoptosis and beta-cell exhaustion, and to impair endothelial function with increased risk for ischemic complications. However, because of the intrinsic pathogenetic heterogeneity of type 2 diabetes, sulfonylureas are likely to remain a therapeutic option. Careful choice of a specific sulfonylurea should be made on the basis of efficacy, safety, convenience, tissue specificity, and neutrality with respect to the beta cell. In this review the advantage:disadvantage ratio of available sulfonylureas is analyzed with the purpose of providing a critical clinical appraisal of the role of sulfonylureas in the modern treatment of type 2 diabetes.

Metformin extended release for the treatment of Type 2 diabetes mellitus

Metformin extended release (ER) (Glumetza, Depomed, Inc.) is a recently approved formulation that provides effective and well-tolerated glycaemic control with once-daily dosing. Metformin ER has similar bioavailability to conventional immediate-release (IR) formulations. In controlled clinical trials, metformin ER provided effective glycaemic control for 24 weeks when administered either as monotherapy or in combination with sulfonylurea. Good glycaemic control was maintained for an additional 24 weeks during an open-label extension study. Once-daily dosing with metformin ER 1500 mg/day was as effective as twice-daily dosing with metformin IR at the same total daily dose. Metformin ER was well tolerated at doses of 1500 or 2000 mg/day, with no increase in the frequency or severity of adverse events at the higher dose.

Increased cancer-related mortality for patients with type 2 diabetes who use sulfonylureas or insulin

OBJECTIVE

Numerous studies have identified an increased risk of cancer in type 2 diabetes. We explored the association between antidiabetic therapies and cancer-related mortality in patients with type 2 diabetes, postulating that agents that increase insulin levels might promote cancer.

RESEARCH DESIGN AND METHODS

This was a population-based cohort study using administrative databases from Saskatchewan Health. Cancer-related mortality was compared among inception cohorts of metformin users and sulfonylurea monotherapy users. Multivariate Cox regression was used to estimate the hazard ratio (HR) of cancer-related mortality, after adjusting for age, sex, insulin use, and chronic disease score. All statistical tests were two-sided.

RESULTS

We identified 10,309 new users of metformin or sulfonylureas with an average follow-up of 5.4 +/- 1.9 years (means +/- SD). The mean age for the cohort was 63.4 +/- 13.3 years, and 55% were men. Cancer mortality over follow-up was 4.9% (162 of 3,340) for sulfonylurea monotherapy users, 3.5% (245 of 6,969) for metformin users, and 5.8% (84 of 1,443) for subjects who used insulin. After multivariate adjustment, the sulfonylurea cohort had greater cancer-related mortality compared with the metformin cohort (adjusted HR 1.3 [95% CI 1.1-1.6]; P = 0.012). Insulin use was associated with an adjusted HR of cancer-related mortality of 1.9 (95% CI 1.5-2.4; P < 0.0001).

CONCLUSIONS

Patients with type 2 diabetes exposed to sulfonylureas and exogenous insulin had a significantly increased risk of cancer-related mortality compared with patients exposed to metformin. It is uncertain whether this increased risk is related to a deleterious effect of sulfonylurea and insulin or a protective effect of metformin or due to some unmeasured effect related to both choice of therapy and cancer risk.

Triple therapy with glimepiride in patients with type 2 diabetes mellitus inadequately controlled by metformin and a thiazolidinedione: results of a 30-week, randomized, double-blind, placebo-controlled, parallel-group study

OBJECTIVE

This study evaluated the efficacy and tolerability of glimepiride in patients with type 2 diabetes mellitus that was inadequately controlled with a combination of immediate- or extended-release metformin and a thiazolidinedione.

METHODS

This was a multicenter, randomized, double-blind, placebo-controlled, parallel-group, 2-arm study consisting of a 4-week stabilization and eligibility period and a 26-week treatment period. Patients with a diagnosis of type 2 diabetes for a minimum of 1 year received glimepiride (titrated sequentially from 2 to 4 to 8 mg/d over 6 weeks, followed by 20 weeks of maintenance therapy) or placebo in combination with an established regimen of immediate- or extended release metformin and rosiglitazone or pioglitazone. The primary efficacy outcome was the change in glycosylated hemoglobin (HbA(1c)) from baseline. The safety analysis was based on the incidence of hypo glycemia, adverse events, and laboratory abnormalities. Changes in lipid levels (high-density lipoprotein cholesterol, total cholesterol, low-density lipoprotein cholesterol, very low density lipoprotein cholesterol, and triglycerides) were evaluated, and health-related quality of life was assessed based on scores on the Diabetes Care Profile (DCP) and Health Utilities Index Mark 3 (HU13).

RESULTS

Of 170 randomized patients, 159 were included in the efficacy analysis and 168 were included in the safety analysis. Demographic variables were similar at baseline between the glimepiride and placebo groups (mean age, 56.5 and 56.4 years, respectively; percent men/women, 61.0%/39.0% and 62.3%/37.7%; weight, 100.9 and 96.3 kg). HbA(1c) was significantly improved at end point with glimepiride combination therapy compared with placebo (mean [SE], -1.31% [0.08] vs -0.33% [0.08], respectively; P < 0.001). The majority of patients (62.2%) who received glimepiride achieved an HbA(1c) value of < or =7%, compared with 26.0% of patients receiving placebo (P < 0.001 between groups). At end point, the adjusted mean differences between treatments significantly favored the glimepiride combination in terms of fasting plasma glucose (-37.4 [4.0] mg/dL; P < 0.001), fasting insulin (4.06 [1.69] microIU/mL; P < 0.03), and C-peptide (124.5 [35.9] pmol/L; P < 0.001). The adjusted mean changes in body mass index from baseline to end point were 1.26 (0.16) kg/m(2) with glimepiride and 0.17 (0.16) kg/m(2) with placebo (P < 0.001). Similarly, the mean change in weight was greater with glimepiride than with placebo (3.76 [0.54] vs 0.45 [0.52] kg; P < 0.001). There were no significant differences in lipid levels between groups. Clinically significant adverse events, laboratory abnormalities, and rates of severe hypoglycemia were similar between treatment groups. The overall incidence of hypoglycemia, however, was 51.2% in the glimepiride group and 8.3% in the placebo group (P < 0.001). In general, there was no significant difference between treatment groups with respect to scores on the DCP or HUI3 over the study period.

CONCLUSIONS

In these patients with type 2 diabetes that was not adequately controlled by dual combination therapy with metformin and a thiazolidinedione, the addition of glimepiride improved glycemic control compared with placebo with an acceptable tolerability profile. Although there were significantly more episodes of hypoglycemia with triple therapy than with dual therapy and placebo, the risk for severe hypoglycemia was low.

Trends in the use of oral antidiabetic drugs by outpatients in Taiwan: 1997-2003

OBJECTIVE

To define the prescribing patterns of oral antidiabetic drugs (OADs) in Taiwan over a 7-year period (1997-2003) and to critically comment on changes observed.

METHODS

A cross-sectional study design was implemented using data from Taiwan's National Health Insurance Research Database between January 1997 and December 2003. Outpatients who were 18 years or older and had at least an OAD claim during the study period were identified. The unit of analysis was each OAD prescription for diabetic outpatient visits. The prescribing trends were described in terms of annual changes in prescribing rates and patterns.

RESULTS

The numbers of OAD prescriptions rose 1.23-fold. The sulfonylurea (SU) class was the most commonly used OAD, but the prescribing rates for this class declined over time. The biguanide (BG) class was the second most frequently prescribed OAD class and its prescribing rate initially increased, peaked in 2000, and then substantially decreased. The largest increase in prescribing was for acarbose use. The prescribing rates of two new classes of OAD, meglitinide (MG) and thiazolidinedione (TZD), also significantly increased within a short period of time. A trend towards combination therapy was observed away from monotherapy. The SU class was the most commonly prescribed as monotherapy. SU plus BG was the most commonly prescribed dual therapy. Triple oral therapy showed a significant ninefold increase.

CONCLUSION

The prescribing rates of OADs are shifting from the older OADs (i.e. SUs) to newer OADs [i.e. alpha-glucosidase inhibitor (AGI), MGs, and TZDs]. The prescribing patterns of OADs are moving toward combination therapy, especially triple oral therapy.

Risk of fatal and nonfatal lactic acidosis with metformin use in type 2 diabetes mellitus

BACKGROUND

Metformin is an oral anti-hyperglycemic agent used in the treatment of type 2 diabetes mellitus. The results of the UK Prospective Diabetes Study indicate that metformin treatment is associated with a reduction in total mortality compared to other anti-hyperglycemic treatments. Metformin, however, is thought to increase the risk of lactic acidosis, and is considered to be contraindicated in many chronic hypoxemic conditions that may be associated with lactic acidosis, such as cardiovascular, renal, hepatic and pulmonary disease, and advancing age.

OBJECTIVES

To assess the incidence of fatal and nonfatal lactic acidosis with metformin use compared to placebo and other glucose-lowering treatments in patients with type 2 diabetes mellitus. A secondary objective was to evaluate the blood lactate levels for those on metformin treatment compared to placebo or non-metformin therapies.

SEARCH STRATEGY

A search was performed of The Cochrane Library (up to 8/2005), MEDLINE (up to 8/2005), EMBASE (up to 11/2000), OLD MEDLINE, and REACTIONS (up to 8/2005), in order to identify all studies of metformin treatment from 1966 to August 2005. The Cumulated Index Medicus was used to search relevant articles from 1959 to 1965. The search was augmented by scanning references of identified articles, and by contacting principal investigators. Date of latest search: August 2005.

SELECTION CRITERIA

Prospective trials in patients with type 2 diabetes that lasted longer than one month were included if they evaluated metformin, alone or in combination with other treatments, compared to placebo or any other glucose-lowering therapy. Observational cohort studies of metformin treatment lasting greater than one month were also included.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected trials to be included, assessed study quality and extracted data. The incidence of fatal and nonfatal lactic acidosis was recorded as cases per patient-years, for metformin treatment and for placebo or other treatments. The upper limit for the true incidence of cases in the metformin and non-metformin groups were calculated using Poisson statistics. In a second analysis lactate levels were measured as a net change from baseline or as mean treatment values (basal and stimulated by food or exercise) for treatment and comparison groups. The pooled results were recorded as a weighted mean difference (WMD) in mmol/L, using the fixed effect model for continuous data.

MAIN RESULTS

Pooled data from 206 comparative trials and cohort studies revealed no cases of fatal or nonfatal lactic acidosis in 47,846 patient-years of metformin use or in 38,221 patients-years in the non-metformin group. Using Poisson statistics with 95% confidence intervals the upper limit for the true incidence of metformin-associated lactic acidosis was 6.3 cases per 100,000 patient-years, and the upper limit for the true incidence of lactic acidosis in the non-metformin group was 7.8 cases per 100,000 patient-years. There was no difference in lactate levels, either as mean treatment levels or as a net change from baseline, for metformin compared to placebo or other non-biguanide therapies. The mean lactate levels were slightly lower for metformin treatment compared to phenformin (WMD -0.75 mmol/L, 95% CI -0.86 to -0.15).

AUTHORS' CONCLUSIONS

There is no evidence from prospective comparative trials or from observational cohort studies that metformin is associated with an increased risk of lactic acidosis, or with increased levels of lactate, compared to other anti-hyperglycemic treatments if prescribed under the study conditions.

Trends and influences on use of antidiabetic drugs in England, 1992-2003

OBJECTIVE

To describe trends in prescribing for glycaemic control in diabetes mellitus in England, 1993-2003, and to examine the effects of new clinical evidence or national guidance on these.

DESIGN

Observational study of prescribing adjusted for extrapolated changes in epidemiology of insulin and non-insulin treated diabetes.

SETTING

Primary care in England, 1992-2003.

DATA SOURCES

Three monthly prescribing data from the Prescription Pricing Authority.

MAIN OUTCOME MEASURES

Defined daily doses/patient/quarter of oral hypoglycaemics and of insulin.

RESULTS

There was an increase in the prevalence of both insulin treated (85%) and non-insulin treated (80%) diabetes. There were increases in all drug use, which were largely explained by this: for example, sulphonylurea use increased by 101% in total but only 11% after correction for change in prevalence and population; insulin use increased by 140% in total, but 33% after correction. Neither guidances from the National Institute of Clinical Excellence nor new clinical evidence had any discernible effect on this. An exception was metformin use, which increased by 495% in total, and by 277% after correction. This increase occurred mainly from early 1998 and seemed to coincide with the publication of evidence of the specific benefits of metformin.

CONCLUSIONS

There has been a trend towards more aggressive treatment of diabetes. National guidance may have reinforced this but has not altered the trend. Specific evidence around metformin may have been very influential in increasing its use.

Does metformin decrease blood pressure in patients with Type 2 diabetes intensively treated with insulin?

AIMS

We investigated in a double-blind study whether metformin reduces blood pressure (BP) in patients with Type 2 diabetes intensively treated with insulin.

METHODS

A total of 220 patients with Type 2 diabetes were asked to undergo 24-h ambulatory BP monitoring (24-h ABPM). One hundred and eighty-two gave informed consent. Eighty-nine were randomized to metformin and 93 to placebo. Thirty-five subjects dropped out (13 placebo, 22 metformin users); 147 patients underwent a second 24-h ABPM, 16 weeks after randomization.

RESULTS

Systolic BP (SBP), diastolic BP (DBP), pulse BP (PP), mean BP (MP) and heart rate (HR) were measured as office BP measurements and as 24-h ABPM for 24-h, day and night. Office BP measurements did not differ significantly between the placebo- and metformin-treated groups for any BP measure, but showed a non-significant trend for SBP reduction with metformin use (mean baseline-adjusted difference, metformin minus placebo: -4.2 mmHg, 95% CI, -9.9 to +1.5; P = 0.15). The baseline-adjusted differences of the ambulatory measurements were -0.2 mmHg (95% CI, -2.9 to +2.6) for the 24-h SBP, and +1.1 mmHg (95% CI, -0.7 to +2.8) for the 24-h DBP. On the whole, BP differences between metformin- and placebo-treated groups were not statistically significant. The only significant difference was for night-time PP (baseline-adjusted difference: -2.2 mmHg; 95% CI, -4.2 to -0.2). These results were not different after adjustment for age and diabetes duration, or for (changes in) body mass index, glycated haemoglobin, insulin dose or plasma homocysteine.

CONCLUSION

Metformin does not significantly affect BP in patients with Type 2 diabetes intensively treated with insulin.

Secondary Failure Rates Associated with Metformin and Sulfonylurea Therapy for Type 2 Diabetes Mellitus

STUDY OBJECTIVE

To determine whether metformin therapy, compared with sulfonylurea therapy, is associated with a delayed onset of secondary failure in patients with type 2 diabetes mellitus.

DESIGN

Retrospective cohort study.

DATA SOURCE

Outpatient prescription database from Saskatchewan Health, Saskatchewan, Canada.

PATIENTS

Two cohorts-5077 individuals receiving sulfonylurea monotherapy and 1652 receiving metformin monotherapy for 2 years or longer-identified from a population of 12,272 new users of oral antidiabetic agents between 1991 and 1996 and who were followed through 1999.

MEASUREMENTS AND MAIN RESULTS

The association between initial drug therapy and onset of secondary failure was evaluated using multivariate Cox proportional hazard models in which the sulfonylurea monotherapy cohort was the reference group. Secondary failure was defined as progression to combination oral therapy or a switch in oral therapy; each component (e.g., time to combination therapy or first switch) of this definition, including start of insulin therapy, was assessed as a secondary outcome. The subjects' mean age was 63.8 years, and 3787 (56.3%) were men. Subjects were followed for a mean +/- SD of 5.7 +/- 1.8 years. Metformin monotherapy was associated with a delay in the onset of secondary failure (hazard ratio [HR] 0.89, 95% confidence interval [CI] 0.82-0.98), in the progression to combination therapy (HR 0.79, 95% CI 0.71-0.87), and in the start of insulin therapy (HR 0.65, 95% CI 0.51-0.82). Of note, patients receiving metformin monotherapy first were more likely than those receiving sulfonylurea monotherapy first to switch treatments (HR 1.43, 95% CI 1.17-1.75).

CONCLUSION

Compared with sulfonylurea therapy, metformin therapy appears to be associated with a delay in the onset of secondary failure.

Long-term efficacy and tolerability of add-on pioglitazone therapy to failing monotherapy compared with addition of gliclazide or metformin in patients with type 2 diabetes

AIMS/HYPOTHESIS

The aim of this analysis was to examine the long-term effects of pioglitazone or gliclazide addition to failing metformin monotherapy and pioglitazone or metformin addition to failing sulphonylurea monotherapy in patients with type 2 diabetes.

METHODS

Two 2-year, randomised, multicentre trials were performed in patients with inadequately controlled type 2 diabetes (HbA1c 7.5-11% inclusive), who were receiving either metformin or a sulphonylurea at > or = 50% of the maximum recommended dose or at the maximum tolerated dose. In the first study, patients on metformin received add-on therapy with pioglitazone (15-45 mg/day, n = 317) or gliclazide (80-320 mg/day, n = 313). In the second study, patients on sulphonylurea therapy were randomised to receive add-on therapy with either pioglitazone (15-45 mg/day, n = 319) or metformin (850-2,550 mg/day, n = 320). HbA(1)c, fasting plasma glucose, insulin and lipids were investigated.

RESULTS

At week 104, the mean reduction from baseline in HbA(1)c was 0.89% for pioglitazone and 0.77% for gliclazide addition to metformin (p = 0.200). There was a statistically significant between-group difference for the change in mean fasting plasma glucose at week 104 (-1.8 mmol/l for pioglitazone vs -1.1 mmol/l for gliclazide, p < 0.001). There were no significant differences in changes from baseline in glycaemic parameters for pioglitazone compared with metformin addition to sulphonylurea therapy. Whether added to metformin or sulphonylurea, pioglitazone caused significantly greater decreases in triglycerides and significantly greater increases in HDL cholesterol than the comparator regimens (p < or = 0.001). There were decreases in LDL cholesterol in the comparator groups and these were significantly different from the small changes observed with pioglitazone (p < 0.001). All treatment regimens were well tolerated. There were weight increases of 2.5 kg and 3.7 kg in the pioglitazone and 1.2 kg in the gliclazide add-on groups, and there was a mean decrease of 1.7 kg in the metformin add-on group.

CONCLUSIONS/INTERPRETATION

As add-on therapy to existing sulphonylurea or metformin therapy, pioglitazone improved glycaemic control and this improvement was sustained over 2 years. Furthermore, there were potential benefits in terms of improvements in specific lipid abnormalities. This could offer an advantage over the addition of other oral agents in the long-term treatment of diabetes.

Effects of exenatide (exendin-4) on glycemic control over 30 weeks in patients with type 2 diabetes treated with metformin and a sulfonylurea

OBJECTIVE

This study evaluated the effects of exenatide, a novel incretin mimetic, in hyperglycemic patients with type 2 diabetes unable to achieve glycemic control with metformin-sulfonylurea combination therapy.

RESEARCH DESIGN AND METHODS

A 30-week, double-blind, placebo-controlled study was performed in 733 subjects (aged 55 +/- 10 years, BMI 33.6 +/- 5.7 kg/m(2), A1C 8.5 +/- 1.0%; means +/- SD) randomized to 5 microg subcutaneous exenatide b.i.d. (arms A and B) or placebo for 4 weeks. Thereafter, arm A remained at 5 microg b.i.d. and arm B escalated to 10 microg b.i.d. Subjects continued taking their dose of metformin and were randomized to either maximally effective (MAX) or minimum recommended (MIN) doses of sulfonylurea.

RESULTS

Week 30 A1C changes from baseline (+/-SE) were -0.8 +/- 0.1% (10 microg), -0.6 +/- 0.1% (5 microg), and +0.2 +/- 0.1% (placebo; adjusted P < 0.0001 vs. placebo), yielding placebo-adjusted reductions of -1.0% (10 microg) and -0.8% (5 microg). In the evaluable population, exenatide-treated subjects were more likely to achieve A1C < or =7% than placebo-treated subjects (34% [10 microg], 27% [5 microg], and 9% [placebo]; P < 0.0001). Both exenatide arms demonstrated significant weight loss (-1.6 +/- 0.2 kg from baseline each exenatide arm, -0.9 +/- 0.2 kg placebo; P < or = 0.01 vs. placebo). Mild or moderate nausea was the most frequent adverse event. The incidence of mild/moderate hypoglycemia was 28% (10 microg), 19% (5 microg), and 13% (placebo) and appeared lower with MIN than with MAX sulfonylurea treatment.

CONCLUSIONS

Exenatide significantly reduced A1C in patients with type 2 diabetes unable to achieve adequate glycemic control with maximally effective doses of combined metformin-sulfonylurea therapy. This improvement in glycemic control was associated with no weight gain and was generally well tolerated.

Long-term efficacy and safety of biphasic insulin aspart in patients with type 2 diabetes

BACKGROUND: In this study, we sought to compare the long-term safety and efficacy of biphasic insulin aspart 30 (BIAsp30) with that of biphasic human insulin 30 (BHI30) over a period of 24 months in patients with type 2 diabetes. METHODS: Patients with type 2 diabetes (n=125) were assigned to twice-daily BIAsp30 or BHI30 and participated in both a 3-month initial period and a 21-month extension of a randomized, controlled, multinational trial. RESULTS: No significant difference was found in mean HbA(1c) after 24 months [BIAsp30, 8.35+/-0.20%; BHI30 8.13+/-0.16%; adjusted mean difference (BIAsp30-BHI30) 0.03 (90% CI -0.29 to 0.34)%, P=0.89]. The proportion of patients experiencing major hypoglycaemia was also similar during the first year (BIAsp30, 5%; BHI30, 8%; P=0.72), but it was significantly lower with BIAsp30 than with BHI30 during the second year (BIAsp30, 0%; BHI30, 10%; P=0.04). The proportion experiencing minor hypoglycaemia was not significantly different. No significant difference was recorded in changes in nonspecific insulin antibody levels after 24 months (BIAsp30, 4.87+/-1.92%; BHI30; 1.00+/-1.66%; P=0.13). Body weight change was 0.05+/-0.81 kg in the BIAsp30 group and 2.00+/-0.69 kg in the BHI30 group (P=0.07). CONCLUSIONS: Reduced major hypoglycaemia compared with BHI30 during the second year of treatment and comparable HbA(1c) levels after 24 months appear to support the hypothesis that the improved pharmacokinetic profile of BIAsp30 may favourably affect the balance between hypoglycaemia and hyperglycaemia in insulin-treated type 2 diabetes.

Effects of exenatide (exendin-4) on glycemic control over 30 weeks in sulfonylurea-treated patients with type 2 diabetes

OBJECTIVE

This study evaluated the ability of the incretin mimetic exenatide (exendin-4) to improve glycemic control in patients with type 2 diabetes failing maximally effective doses of a sulfonylurea as monotherapy.

RESEARCH DESIGN AND METHODS

This was a triple-blind, placebo-controlled, 30-week study conducted at 101 sites in the U.S. After a 4-week, single-blind, placebo lead-in period, 377 subjects were randomized (60% men, age 55 +/- 11 years, BMI 33 +/- 6 kg/m(2), HbA(1c) 8.6 +/- 1.2% [+/-SD]) and began 4 weeks at 5 microg subcutaneous exenatide twice daily (before breakfast and dinner; arms A and B) or placebo. Subsequently, subjects in arm B were escalated to 10 microg b.i.d. exenatide. All subjects continued sulfonylurea therapy.

RESULTS

At week 30, HbA(1c) changes from baseline were -0.86 +/- 0.11, -0.46 +/- 0.12, and 0.12 +/- 0.09% (+/-SE) in the 10-microg, 5-microg, and placebo arms, respectively (adjusted P < 0.001). Of evaluable subjects with baseline HbA(1c) > 7% (n = 237), 41% (10 microg), 33% (5 microg), and 9% (placebo) achieved HbA(1c) <or= 7% (P < 0.001). Fasting plasma glucose concentrations decreased in the 10-microg arm compared with placebo (P < 0.05). Subjects in the exenatide arms had dose-dependent progressive weight loss, with an end-of-study loss in the 10-microg exenatide arm of -1.6 +/- 0.3 kg from baseline (P < 0.05 vs. placebo). The most frequent adverse events were generally mild or moderate and gastrointestinal in nature. No severe hypoglycemia was observed.

CONCLUSIONS

Exenatide significantly reduced HbA(1c) in patients with type 2 diabetes failing maximally effective doses of a sulfonylurea. Exenatide was generally well tolerated and was associated with weight loss.