Association between oral antidiabetic use, adverse events and outcomes in patients with type 2 diabetes

The effects of metformin on weight loss in women with gestational diabetes: a pilot randomized, placebo-controlled trial

OBJECTIVE

We sought to compare weight loss in the first 6 weeks postpartum among women with gestational diabetes mellitus (GDM) treated with metformin or placebo, a promising therapy to reduce later risk of progression to diabetes mellitus.

STUDY DESIGN

We conducted a pilot, randomized trial of metformin vs placebo in postpartum women with GDM. Women with pre-GDM, unable to tolerate metformin, resumed on insulin or oral hypoglycemic agent, delivered <34 weeks' gestation, or with a body mass index <20 kg/m(2) were excluded. Women were randomized to either metformin 850 mg daily for 7 days, then metformin 850 mg twice a day for the next 5 weeks or placebo prescribed in a similar frequency. The subject, health care provider, and research staff were blinded to the treatment. The primary outcome was weight change from delivery to 6 weeks postpartum. Secondary outcomes included the percentage of women achieving their self-reported prepregnancy weight, reported medication adherence, adverse effects, and satisfaction. Differences in weight change between groups were determined by Wilcoxon rank sum test and in achieving prepregnancy weight by χ(2) test.

RESULTS

Of 114 women randomized, 79 (69.3%) completed the 6 weeks; 36 (45.6%) were randomized to metformin and 43 (54.4%) to placebo. Metformin and placebo groups were similar in median weight loss (6.3 kg [range, -0.3 to 19.8] vs 6.5 kg [range, -0.3 to 12.1], P = .988) and percentage of women achieving reported prepregnancy weight (41.7 vs 37.2%, P = .69). Self-reported adherence in taking >50% of medication was 75% at 3 weeks and 97% at 6 weeks. Nausea, diarrhea, and hypoglycemia were reported in approximately 11-17% of women and 56-63% reported dissatisfaction with the medication.

CONCLUSION

Women with GDM lost approximately 6 kg by 6 weeks' postpartum. This was similar in both groups and resulted in <50% of women achieving their prepregnancy weight. Although the reported adherence and satisfaction with the medication was high, adverse effects were reported with nearly 1 in 5 women including nausea, diarrhea, and hypoglycemia. Contrary to expectation, we found no evidence of benefit from metformin. However, longer treatment periods and larger studies with minimal attrition may be warranted.

Addressing policy needs for prevention and control of type 2 diabetes in India

India carries nearly one-fifth of the global burden of diabetes cases, the majority of which are of type 2 diabetes. Recognising the need for controlling diabetes, the Government of India has initiated a national level programme for prevention and control of diabetes along with other non-communicable diseases in 2008. Despite being piloted and implemented, there is hardly any published literature about the national level situation of diabetes and its control efforts. The present article is written with the aim to fill this gap to some extent and to provide a situational analysis of the diabetes problem in India in a holistic way, addressing policy needs for the national programme. It focuses on three main areas, namely, awareness of diabetes, costs of drugs for its treatment and healthcare-system related issues. It argues that poor coverage and weak implementation of the national level programme are major forces that push patients to seek help in the weakly regulated private sector. Approaching the private sector is likely to increase the cost of care, which in turn can lead to an increased financial burden for patients and their families due to factors such as patients' lack of awareness about diabetes, poor drug price regulation and prescriptions including combinations and/or patented products of medicines used for treating diabetes by the private sector. This article addresses several needs such as strengthening the national programme and increasing its reach to unreached districts, exerting drug price regulation and implementing community-based participatory programmes for prevention and management of type 2 diabetes. It also underscores a need for piloting and implementing a robust national level electronic reporting system for diabetes programmes.

Antidiabetic potential of some less commonly used plants in traditional medicinal systems of India and Nigeria

The incidence of diabetes mellitus continue to rise annually all over the world with India and Nigeria having recorded cases of 65.1 and 3.9 million respectively in 2013 and expected to increase by a large amount in 2035. Hyperglycemia is a pre-condition for the development of diabetic complications and is accompanied by an increase in the production of free radicals. The present available treatment option for diabetes like sulfonylurea, metformin and alpha-glucosidase are restricted by their limited actions, secondary failure rates, and side-effects; and unaffordable to the majority of the population. Hence, the need to screen for more medicinal plants with antidiabetic ability due to the fact that plants are; biodegradable, safe and cheap with fewer side-effects. In this review article, we have presented the current status of diabetes in India and Nigeria and the role of some less commonly used medicinal plants from both countries that have antidiabetic potential.

Antihyperglycaemic treatment patterns, observed glycaemic control and determinants of treatment change among patients with type 2 diabetes in the United Kingdom primary care: a retrospective cohort study

BACKGROUND

The initial treatment strategy for patients with type 2 diabetes includes lifestyle change recommendations. When patients are not successful in controlling their blood glucose levels through healthier lifestyle pharmaceutical agents are recommended. The objective of this study is to identify determinants of initial treatment change following initiation of non-insulin antihyperglycaemic treatment (OAD) for UK patients with type 2 diabetes.

METHODS

A retrospective cohort study using primary care data from the Clinical Practice Research Datalink between January 2006 and February 2011. Each patient had an OAD prescription. The main treatment pattern outcomes were discontinuation, switching, augmentation and initiation of insulin. Glycaemic control was assessed using HbA1c.

RESULTS

63,060 patients initiated OAD therapy 2006-2010 and 3.4% were prescribed insulin during follow-up. 26% with at least four years of follow-up remained on the initial treatment. Metformin dominated (90%) in UK primary care. Around 75% had a record of HbA1c testing prior to initiating therapy. On initiating OAD, half the patients had HbA1c values >65 mmol/mol and one quarter >80 mmol/mol. The initial values of HbA1c were reduced after 12 months and remained stable. There were 15%-18% of patients whose values increased since initiating OAD. Increased baseline HbA1c is associated with increased chance of augmentation and decreased chance of discontinuation. HbA1c values at 1 year were associated with a three-fold increase in the chance of augmentation, 130% increase in the chance of switching and 14% increase in the chance of discontinuation with each 10 mmol/mol increase. Following initiation of OAD, HbA1c was reduced by an average of 16 mmol/mol during the first year.

CONCLUSION

There are patients for whom glycaemic control worsens and a majority remained above the recommended level, suggesting an unmet need despite the availability of many OAD.

The safety of dipeptidyl peptidase-4 (DPP-4) inhibitors or sodium-glucose cotransporter 2 (SGLT-2) inhibitors added to metformin background therapy in patients with type 2 diabetes mellitus: a systematic review and meta-analysis

The aim of the present meta-analysis was to assess the safety profile of dipeptidyl peptidase-4 (DPP-4) inhibitors and sodium-glucose cotransporter 2 (SGLT-2) inhibitors in comparison with placebo as add-on to metformin therapy in patients with type 2 diabetes. Randomized controlled trials and controlled clinical trials were identified by searching Pubmed, Embase and the Cochrane Central Register of Controlled Trials database until 15 July 2013. All included studies were critically appraised and analysed with the use of Review Manager 5.1.0 software according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement protocol. Twenty randomized and double-blinded studies published in 22 articles fulfilled the inclusion criteria for meta-analysis. The overall results demonstrated that the use of oral antidiabetic agents (analysed separately and together) was not associated with any significantly increased risk of any serious adverse events including hypoglycaemia and gastrointestinal disorders. Moreover, the use of DPP-4 or SGLT-2 inhibitors significantly decreased risk of diarrhoea compared with placebo, when given concomitantly with metformin. However, we found that the SGLT-2 inhibitors were more likely to cause a genital infection. Despite some limitations, the findings of this meta-analysis indicate that DPP-4 or SGLT-2 inhibitors have favourable safety profile, and such therapy, when combined with metformin is well tolerated.

Evaluation of the relationship between weight change and glycemic control after initiation of antidiabetic therapy in patients with type 2 diabetes using electronic medical record data

AIMS

This study evaluates the relationship between HbA1c and weight change outcomes by anti-diabetic weight-effect properties in patients newly treated for type 2 diabetes; a relationship not previously characterized.

METHODS

Electronic medical records of patients with type 2 diabetes newly prescribed anti-diabetic monotherapy were assessed to identify HbA1c goal attainment [(<53 mmol/mol)] and weight change at 1-year. Anti-diabetics were categorized by weight-effect properties: weight-gain (sulfonylureas, thiazolidinediones) and weight-loss/neutral (metformin, DPP-4 inhibitors, GLP-1 agonists). Logistic regression analyses identified likelihood of attaining HbA1c goal or ≥3% weight loss by anti-diabetic category controlling for baseline characteristics. MANOVA was used to identify correlation between changes in weight and HbA1c.

RESULTS

The study included 28,290 patients. Mean age ± sd was 61 years ±11.8. Baseline HbA1c was 7.4% ± 1.6 (57 mmol/mol ± 17); 67.3% were prescribed a weight-loss/neutral anti-diabetic. At 1-year, more patients in the weight-loss/neutral anti-diabetic category lost weight (≥3%) than in the weight-gain anti-diabetic category (40.4% vs. 24.2%, p<0.001) or had an HbA1c<7.0% (<53 mmol/mol) (71.1% vs. 63.8%, p<0.001). Those prescribed a weight-gain anti-diabetic were 53% less likely to lose weight and 29% less likely to be at HbA1c goal than those prescribed a weight-loss/neutral anti-diabetic (p<0.001). Weight loss and HbA1c outcomes were significantly correlated (p<0.001).

CONCLUSIONS

Weight loss of ≥3% was associated with better glycemic control in patients newly treated for type 2 diabetes. Anti-diabetics associated with weight-loss/neutrality were associated with greater weight loss and HbA1c goal attainment and may facilitate efforts to co-manage weight and glycemia in the ambulatory-care setting.

Prognostic implications of DPP-4 inhibitor vs. sulfonylurea use on top of metformin in a real world setting - results of the 1 year follow-up of the prospective DiaRegis registry

BACKGROUND

DPP-4 inhibitors (DPP4-I) have been shown to provide non-inferior glycaemic control compared with sulfonylureas (SU), but result in a reduction of body weight and a significantly lower risk of hypoglycaemia in patients with type 2 diabetes. We aimed to validate these results in a large real-world sample of patients participating in the prospective DiaRegis registry and to assess prognostic implications.

METHODS

DiaRegis included 3810 patients with type 2 diabetes in which antidiabetic therapy was intensified. We defined two patient subgroups, the first receiving either a DPP4-I or SU on top of prior metformin monotherapy and the second containing patients out of subgroup 1 with unaltered treatment for 1 year.

RESULTS

After enrolment 884 patients with prior metformin monotherapy received a dual combination of metformin with either DPP4-I (n = 628; 71%) or SU (n = 256; 29%). Patient characteristics, blood glucose and blood pressure control as well as comorbidity burden were virtually identical. There were neither significant differences in the change of HbA1c over the 12 months treatment period nor in the reduction of body weight, but fasting (p = 0.033) and postprandial glucose levels (p = 0.01) were significantly lower in those receiving DPP4-I. Hypoglycaemia was significantly less frequent in patients receiving DPP4-I (OR 0.32; 95% CI 0.19-0.54). Qualitative changes were robust for subgroup 2 (except of fasting plasma glucose). Patients receiving DPP4-I had significantly less stroke/transitory ischaemic attack (0.2 vs. 2.0; p < 0.05) during the 1 year follow-up, whereas other vascular events (coronary artery bypass graft, percutaneous coronary intervention) were borderline significant.

CONCLUSIONS

The present results confirm prior randomised controlled trial results in patients with type 2 diabetes from real world clinical practice demonstrating that DPP4-I on top of prior metformin monotherapy result in similar HbA1c reductions within 12 months but a significant reduction in hypoglycaemia compared with sulfonylurea added to metformin. The reduction in vascular events observed has to be verified in larger cohorts.

The cost-effectiveness of saxagliptin versus NPH insulin when used in combination with other oral antidiabetes agents in the treatment of type 2 diabetes mellitus in Poland

BACKGROUND

This study compared the health and economic benefits of saxagliptin versus insulin as second-line therapy with either metformin (MET) or sulfonylurea (SU) after failure of the respective monotherapies for patients with type 2 diabetes in Poland.

METHODS

The cost-effectiveness was assessed using a previously published diabetes model. Disease progression, utilities, and effects of changes in glycosylated hemoglobin (HbA1c), weight, and hypoglycemic events were taken from published studies, and Polish sources were used where possible.

RESULTS

MET + saxagliptin reduced severe hypoglycemic complications and weight versus MET + insulin, with an incremental benefit of 0.13 quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratio (ICER) of 27,454 Polish zloty (PLN) ($9,966 U.S.) per QALY gained. SU + saxagliptin showed an incremental benefit of 0.14 QALYs and ICER of 24,663 PLN ($8,953 U.S.) per QALY gained versus SU + insulin, with reduced incidence of symptomatic and severe hypoglycemias. Results were most sensitive to disutilities associated with weight gain, hypoglycemia, injection fear, HbA1c changes, threshold for switching treatment, and patients' age. Results were robust to various model assumptions and inputs. Using a willingness-to-pay threshold of 100,000 PLN ($36,300 U.S.) per QALY gained, the probability that saxagliptin is cost-effective in these analyses was 74% (MET) and 76% (SU).

CONCLUSIONS

Saxagliptin in combination with MET or SU is likely to represent a cost-effective treatment option in Polish patients with type 2 diabetes failing first-line treatment.

Adherence and satisfaction with oral hypoglycemic medications: a pilot study in Palestine

OBJECTIVES

Diabetes mellitus is a chronic progressive disease characterized by numerous health complications. Medication adherence is an important determinant of therapeutic outcome. Few studies on medication adherence have been published from the Arab countries. Therefore, the objective of this pilot study was to assess hypoglycemic medication adherence and its association with treatment satisfaction.

SETTING

Military Medical Services clinic in Nablus, Palestine.

METHODS

This is a cross sectional descriptive study. A convenience sample of 131 diabetic patients was studied. The 8-item Morisky Medication Adherence Scale (MMAS-8) and Treatment Satisfaction Questionnaire for Medication were used to assess adherence and treatment satisfaction, respectively. Statistical Package for Social Sciences was used for statistical analysis.

MAIN OUTCOME MEASURE

Level of adherence, treatment satisfaction and association between adherence and treatment satisfaction among diabetic patients.

RESULTS

According to MMAS-8, 50 patients (38.5%) had a high adherence, 58 (44.6%) had a medium adherence and 22 (16.9%) had a low adherence rate. The mean scores of satisfaction domains were 71 ± 17.6 and 95 ± 16.4 for effectiveness (EFF) and side effects (SE), respectively. Adherence score was a positively and significantly correlated with EFF satisfaction domain (P < 0.01) and age (P = 0.01). Similar significant correlation was found between adherence level and duration of illness (P = 0.047). However, adherence was not significantly associated with gender (P = 0.2), number of hypoglycemic medications (P = 0.5) or SE satisfaction domain (P = 0.2).

DISCUSSION AND CONCLUSION

The majority of diabetic patients in this pilot study were non-adherent. Improving patients' treatment satisfaction will improve treatment adherence.

Gestational diabetes mellitus: Non-insulin management

Gestational diabetes mellitus (GDM) complicates a substantial number of pregnancies. There is consensus that in patients of GDM, excellent blood glucose control, with diet and, when necessary, oral hypoglycemics and insulin results in improved perinatal outcomes, and appreciably reduces the probability of serious neonatal morbidity compared with routine prenatal care. Goals of metabolic management of a pregnancy complicated with GDM have to balance the needs of a healthy pregnancy with the requirements to control glucose level. Medical nutrition therapy is the cornerstone of therapy for women with GDM. Surveillance with daily self-monitoring of blood glucose has been found to help guide management in a much better way than blood glucose checking in labs and clinics, which tends to be less frequent. Historically, insulin has been the therapeutic agent of choice for controlling hyperglycemia in pregnant women. However, difficulty in medication administration with multiple daily injections, potential for hypoglycemia, and increase in appetite and weight make this therapeutic option cumbersome for many pregnant patients. Use of oral hypogycemic agents (OHAs) in pregnancy has opened new vistas for GDM management. At present, there is a growing acceptance of glyburide (glibenclamide) use as the primary therapy for GDM. Glyburide and metformin have been found to be safe, effective and economical for the treatment of gestational diabetes. Insulin, however, still has an important role to play in GDM. GDM is a window of opportunity, which needs to be seized, for prevention of diabetes in future life. Goal of our educational programs should be not only to improve pregnancy outcomes but also to promote healthy lifestyle changes for the mother that will last long after delivery. Team effort on part of obstetricians and endocrinologists is required to make "the diabetes capital of the world" into "the diabetes care capital of the world".

The relationship between patient-reported tolerability issues with oral antidiabetic agents and work productivity among patients having type 2 diabetes

OBJECTIVE

To investigate the association between reported oral antidiabetic tolerability issues and work productivity, activity impairment, and indirect costs.

METHODS

Data were collected from the 2006 to 2008 US National Health and Wellness Survey and the Lightspeed Research, using an Internet-based questionnaire (N = 2074).

RESULTS

Absenteeism, presenteeism, overall work impairment, and activity impairment increased as the number of tolerability issues increased. Similar results were observed using a diabetes-specific productively measure. Total annual adjusted indirect costs (absenteeism and presenteeism costs summed) were $2759, $5533, $7537, and $8405 for patients with 1, 2, 3, and 4 or more tolerability issues, respectively.

CONCLUSIONS

The consideration of tolerability profiles of oral antidiabetic agents may lead to improved productivity among treated patients. Furthermore, targeted educational programs regarding risks and management of these issues to employees with type 2 diabetes mellitus may benefit both employers and patients.

Saxagliptin is non-inferior to glipizide in patients with type 2 diabetes mellitus inadequately controlled on metformin alone: a 52-week randomised controlled trial

AIM

To assess the efficacy and safety of saxagliptin vs. glipizide as add-on therapy to metformin in patients with type 2 diabetes mellitus and inadequate glycaemic control on metformin alone.

METHODS AND PATIENTS

A total of 858 patients [age ≥ 18 years; glycated haemoglobin (HbA(1c) ) > 6.5 - 10.0%; on stable metformin doses ≥ 1500 mg/day] were randomised 1 : 1 to saxagliptin 5 mg/day or glipizide up-titrated as needed from 5 to 20 mg/day for 52 weeks. The primary objective was to assess if the change from baseline HbA(1c) achieved with saxagliptin plus metformin was non-inferior to glipizide plus metformin.

RESULTS

The per-protocol analysis demonstrated non-inferiority of saxagliptin vs. glipizide; adjusted mean changes from baseline HbA(1c) were -0.74% vs. -0.80%, respectively; the between-group difference was 0.06% (95% CI, -0.05% to 0.16%). Treatment with saxagliptin vs. glipizide was associated with a significantly smaller proportion of patients with hypoglycaemic events (3.0% vs. 36.3%; p < 0.0001) and a divergent impact on body weight (adjusted mean change from baseline -1.1 kg with saxagliptin vs. 1.1 kg with glipizide; p < 0.0001). There was a significantly smaller rise in HbA(1c) (%/week) from week 24 to 52 with saxagliptin vs. glipizide (0.001% vs. 0.004%; p = 0.04) indicating a sustained glycaemic effect beyond week 24. Excluding hypoglycaemic events, the proportion of patients experiencing adverse events (AEs) was similar (60.0% saxagliptin vs. 56.7% glipizide); treatment-related AEs were less common with saxagliptin vs. glipizide (9.8% vs. 31.2%), attributable to the higher frequency of hypoglycaemia in glipizide patients. Discontinuation rates resulting from AEs were similar (∼4%).

CONCLUSION

Saxagliptin plus metformin was well tolerated, provided a sustained HbA(1c) reduction over 52 weeks, and was non-inferior to glipizide plus metformin, with reduced body weight and a significantly lower risk of hypoglycaemia.

Assessment of time to follow-up visits in newly-treated hypertensive patients using an electronic medical record database

OBJECTIVE

Use of electronic medical record (EMR) data for evaluating healthcare processes and outcomes is relatively new. Using EMR data, this study evaluated the time from antihypertensive initiation to the first follow-up office visit controlling for adverse events (AEs) and other factors that could influence follow-up timing. Findings were compared to treatment guidelines which recommend monthly follow-up in treatment naive patients until blood pressure (BP) levels are controlled.

RESEARCH DESIGN AND METHODS

Treatment-naïve hypertensive adult patients in the General Electric Centricity EMR database (1996-2006) with a new antihypertensive prescription were evaluated. Time from treatment initiation to first office visit was identified and stratified by occurrence of AEs and therapy change. BP was assessed at 120 +/- 30 days.

RESULTS

The mean +/- SD time from first antihypertensive prescription (index date) to the first office visit was 96.2 +/- 160.6 days; 38% returned within a month of treatment initiation. Controlling for baseline demographic and clinical characteristics, the adjusted time until first office visit was shorter for those with an AE and therapy change than for those with neither event (61 vs. 158 days). Of the patients with follow-up BP data for analysis (n = 27,875), more of those seen within a month of treatment initiation achieved BP goal at 120 days (<140/90 mmHg) than those who were not seen within a month (64.3 vs. 61.7% respectively; p < 0.001).

CONCLUSIONS

This study demonstrates that EMR data can be used to assess quality measures which in turn can inform efforts to improve treatment outcomes. Specifically, this study evaluated mean time to first office visit after antihypertensive therapy initiation controlling for clinical factors that could influence office visit intervals based on data available in a national EMR dataset. A key limitation of this study is that the EMR may not represent patient care delivered by other providers, thus, use of antihypertensives, changes in therapy, and office visits may be underreported.

Patient-reported tolerability issues with oral antidiabetic agents: Associations with adherence; treatment satisfaction and health-related quality of life

AIMS

The study's aim was to quantify prevalence of tolerability issues among patients with T2DM currently treated with OADs and to assess its association with treatment adherence, satisfaction and health-related quality of life (HRQL).

METHODS

Data were collected from the 2006-2008 US National Health and Wellness Survey and the Ailment Panel of Lightspeed Online Research, an internet-based questionnaire. Participants (N=2074) self-reported a diagnosis of T2DM, were >18 years of age and currently taking >1 OADs but not insulin, and spoke English.

RESULTS

The majority (71.7%) experienced at least 1 tolerability issue in the past 2 weeks; 49.7% experienced >2. Tolerability issues included signs/symptoms of hypoglycemia (57.2%), constipation/diarrhea (28%), headaches (25.6%), weight gain (22.9%) and water retention (21.0%). There was a significant association between the number of tolerability issues and both the likelihood of non-adherence (r=0.20, p<0.01) and reduced treatment satisfaction (r=-0.42, p<0.01). Each additional tolerability issue was associated with 28% greater likelihood of medication non-adherence. Constipation/diarrhea (b=-0.02, p<0.01) and symptoms of hypoglycemia (b=-0.08, p<0.01) were significantly associated with lower HRQL scores.

CONCLUSIONS

Optimizing OAD therapy of T2DM by improving tolerability may increase patient satisfaction, medication adherence and HRQL, and may increase the likelihood of attaining treatment goals.

Comparison of daily insulin dose and other antidiabetic medications usage for type 2 diabetes patients treated with an analog basal insulin

OBJECTIVE

Few comparisons of real-world insulin detemir (DET) and insulin glargine (GLAR) utilization have been conducted, which would assist payers and other healthcare decision makers assess the cost effectiveness of these treatment alternatives. The aim of this study was to compare the amount of insulin utilized in a large cohort of patients with type 2 diabetes treated with either DET or GLAR in the real-world setting considering the use of other antidiabetic agents.

RESEARCH DESIGN AND METHODS

A nested case-control study was conducted using data from a large US medical and pharmacy claims data warehouse. Adults with type 2 diabetes newly treated with DET or GLAR were included. From this overall cohort, a subset of DET patients were matched 1:1 to GLAR on age, baseline antidiabetic use, and comorbidities. Descriptive statistics were used to compare patient characteristics between treatment groups; a Wilcoxon rank sum test was used to compare insulin utilization in terms of the patient level daily average consumption (DACON).

MAIN OUTCOMES MEASURES

Mean DACON by analog basal insulin.

RESULTS

This study included 18,763 patients; 2215 (11.8%) were treated with DET and 16,548 (88.2%) with GLAR. DET patients were slightly younger (59.6 vs. 60.3 years; p < or = 0.01); gender did not differ (46% female). From the overall cohort, 1581 DET patients were matched to 1581 GLAR patients. Mean (median) DACON did not differ overall (35 [26] units for DET vs. 32 [27] units for GLAR; p = 0.06) or in the matched cohort (35 [26] units for DET vs. 32 [27] units for GLAR; p = 0.146). In the matched cohort, there were no differences in non-insulin antidiabetic use after DET or GLAR was started.

CONCLUSIONS

In a real-world setting, insulin utilization did not differ between DET and GLAR controlling for patient characteristics and considering concomitant antidiabetic treatments, which could influence insulin use. A limitation is that the dispensing data as used in this study may not accurately reflect daily insulin dose because patients may discard unused insulin portions when the vial or pre-filled syringe reaches its in-use expiration date. Additional research is warranted to determine if there are differences in DET and GLAR utilization over time.

Analysis of glycaemic control and weight change in patients initiated with human or analog insulin in an US ambulatory care setting

BACKGROUND

Insulin is a mainstay in the treatment of type 1 diabetes and is a recommended option in patients with type 2 diabetes who fail to maintain glycaemic control on other non-insulin therapies. The purpose of this study was to describe patient characteristics and evaluate changes in glycaemic control and weight in patients treated with insulin in an ambulatory care setting.

METHODS

Patients with diabetes were identified from the General Electric electronic medical record (EMR) database (1 September 2004 to 30 April 2008). Patients were > or =18 years, insulin naive, newly treated with monoinsulin therapy (index date). Baseline characteristics were identified overall and stratified by insulin type (basal, mixed, and rapid). Basal insulins were described by human versus analog and for insulin detemir and insulin glargine. Change in haemoglobin A1C (HbA1C) and weight from baseline (45 days pre- to 15 days postindex date) to 6 months (+/-90 days) were compared. Regression analyses were used to evaluate HbA1C outcomes across insulins and for the likelihood of gaining 0.9 kg (2 lbs) for detemir versus glargine controlling for baseline characteristics.

RESULTS

A total of 12 136 patients were included. A majority were initiated on a basal insulin (64.7%) followed by mixed (20.8%) and rapid (14.4%). Basal users had significantly higher mean body weight and lower mean baseline HbA1C than mixed users (p < 0.001 for all), and were significantly older, had higher baseline HbA1C and higher baseline body mass index (BMI) than rapid insulin users (p < 0.001 for all). Glargine patients had a significantly higher mean baseline HbA1C (p = 0.003) than detemir patients. The adjusted reduction in HbA1C was greater for rapid insulin than for mixed or basal insulin (p < or = 0.05). The adjusted differences in HbA1C between basal human and basal analog insulins and between detemir and glargine were not statistically significant (p > 0.05). Patients using detemir were 30% less likely to gain 0.9 kg or more than glargine users (p < 0.05).

CONCLUSIONS

HbA1C outcomes in the ambulatory care setting were generally not different between insulin classes. The likelihood of weight gain was less with insulin detemir than with insulin glargine. Thus, real-world weight outcomes for basal analog insulin may differ by specific product.

Saxagliptin added to a submaximal dose of sulphonylurea improves glycaemic control compared with uptitration of sulphonylurea in patients with type 2 diabetes: a randomised controlled trial

AIMS

Assess the efficacy and safety of saxagliptin added to a submaximal sulphonylurea dose vs. uptitration of sulphonylurea monotherapy in patients with type 2 diabetes and inadequate glycaemic control with sulphonylurea monotherapy.

METHODS AND PATIENTS

A total of 768 patients (18-77 years; HbA(1c) screening >or= 7.5 to <or= 10.0%) were randomised and treated with saxagliptin 2.5 or 5 mg in combination with glyburide 7.5 mg vs. glyburide 10 mg for 24 weeks. Blinded uptitration glyburide was allowed in the glyburide-only arm to a maximum total daily dose of 15 mg. Efficacy analyses were performed using ANCOVA and last-observation-carried-forward methodology.

RESULTS

At week 24, 92% of glyburide-only patients were uptitrated to a total glyburide dose of 15 mg/day. Saxagliptin 2.5 and 5 mg provided statistically significant adjusted mean decreases from baseline to week 24 vs. uptitrated glyburide, respectively, in HbA(1c) (-0.54%, -0.64% vs. +0.08%; both p < 0.0001) and fasting plasma glucose (-7, -10 vs. +1 mg/dl; p = 0.0218 and p = 0.002). The proportion of patients achieving an HbA(1c) < 7% was greater for saxagliptin 2.5 and 5 mg vs. uptitrated glyburide (22.4% and 22.8% vs. 9.1%; both p < 0.0001). Postprandial glucose area under the curve was reduced for saxagliptin 2.5 and 5 mg vs. uptitrated glyburide (-4296 and -5000 vs. +1196 mg.min/dl; both p < 0.0001). Adverse event occurrence was similar across all groups. Reported hypoglycaemic events were not statistically significantly different for saxagliptin 2.5 (13.3%) and 5 mg (14.6%) vs. uptitrated glyburide (10.1%).

CONCLUSION

Saxagliptin added to submaximal glyburide therapy led to statistically significant improvements vs. uptitration of glyburide alone across key glycaemic parameters and was generally well tolerated.