Relationship of baseline HbA1c, HbA1c change and HbA1c target of < 7% with insulin analogues in type 2 diabetes: a meta-analysis of randomised controlled trials

A study of factors influencing long-term glycemic variability in patients with type 2 diabetes: a structural equation modeling approach

Aim

The present study aims to utilize structural equation modeling (SEM) to investigate the factors impacting long-term glycemic variability among patients afflicted with type 2 diabetes.

Method

The present investigation is a retrospective cohort study that involved the collection of data on patients with type 2 diabetes mellitus who received care at a hospital located in Chengdu, Sichuan Province, over a period spanning from January 1, 2013, to October 30, 2022. Inclusion criteria required patients to have had at least three laboratory test results available. Pertinent patient-related information encompassing general demographic characteristics and biochemical indicators was gathered. Variability in the dataset was defined by standard deviation (SD) and coefficient of variation (CV), with glycosylated hemoglobin variation also considering variability score (HVS). Linear regression analysis was employed to establish the structural equation models for statistically significant influences on long-term glycemic variability. Structural equation modeling was employed to analyze effects and pathways.

Results

Diabetes outpatient special disease management, uric acid variability, mean triglyceride levels, mean total cholesterol levels, total cholesterol variability, LDL variability, baseline glycated hemoglobin, and recent glycated hemoglobin were identified as significant factors influencing long-term glycemic variability. The overall fit of the structural equation model was found to be satisfactory and it was able to capture the relationship between outpatient special disease management, biochemical indicators, and glycated hemoglobin variability. According to the total effect statistics, baseline glycated hemoglobin and total cholesterol levels exhibited the strongest impact on glycated hemoglobin variability.

Conclusion

The factors that have a significant impact on the variation of glycosylated hemoglobin include glycosylated hemoglobin itself, lipids, uric acid, and outpatient special disease management for diabetes. The identification and management of these associated factors can potentially mitigate long-term glycemic variability, thereby delaying the onset of complications and enhancing patients' quality of life.

Effects of switching from liraglutide to semaglutide or dulaglutide in patients with type 2 diabetes: A randomized controlled trial

INTRODUCTION

Few studies have examined the effects of glucagon-like peptide-1 receptor agonist switching, particularly in Japanese patients. Therefore, we aimed to investigate the effects of switching from liraglutide to semaglutide or dulaglutide on blood glucose, body weight, and the occurrence of adverse effects in clinical practice.

MATERIALS AND METHODS

This was an open-label, prospective, randomized, parallel-group controlled trial. Patients with type 2 diabetes treated with liraglutide (0.6 or 0.9 mg) at Yokosuka Kyosai Hospital in Japan were recruited from September 2020 to March 2022 and, after obtaining informed consent, randomly assigned to the semaglutide or dulaglutide group (1:1). Changes in the glycated hemoglobin level from baseline to weeks 8, 16, and 26 were evaluated post-treatment.

RESULTS

Initially, 32 participants were enrolled, of whom 30 completed the study. Glycemic control was significantly better in the semaglutide group than in the dulaglutide group (-0.42 ± 0.49% vs -0.00 ± 0.34%, P = 0.0120). Body weight significantly decreased in the semaglutide group (-2.6 ± 3.6 kg, P = 0.0153), whereas no change was observed in the dulaglutide group (-0.1 ± 2.7 kg, P = 0.8432). We found a significant difference in body weight between the groups (P = 0.0469). The proportion of participants who reported adverse events was 75.0% and 18.8% in the semaglutide and dulaglutide groups, respectively. One patient in the semaglutide group had difficulty continuing treatment due to severe vomiting and weight loss.

CONCLUSIONS

Switching from once-daily liraglutide to once-weekly semaglutide 0.5 mg significantly improved glycemic control and body weight compared with switching to once-weekly dulaglutide 0.75 mg.

Impact of continuous glucose monitoring on glycemic control and its derived metrics in type 1 diabetes: a longitudinal study

Aim

We explored the effectiveness of continuous glucose monitoring for 1 year on glycated A1c reduction in adults with type 1 diabetes mellitus.

Methods

We included type 1 diabetes mellitus adults who were either new continuous glucose monitoring users (N = 155) or non-users who were under standard care (N = 384). Glycated A1c was measured at baseline and 3, 6, 9, and 12 months. Individuals with (N = 155) or without continuous glucose monitoring use (N = 310) were matched 1:2 by propensity score. We used the linear mixed models to identify the quantitative reduction in repeated measures of glycated A1c.

Results

The change in glycated A1c from baseline to 12 months was -0.5% ± 1.0% for the continuous glucose monitoring user group (N = 155, P < 0.001) and -0.01% ± 1.0% for the non-user group (N = 310, P = 0.816), with a significant difference between the two groups (P = 0.003). Changes in glycated A1c were significant at 3, 6, 9, and 12 months compared with those at baseline in patients using continuous glucose monitoring (P < 0.001), and the changes differed significantly between the groups (P < 0.001). A linear mixed model showed an adjusted treatment group difference in mean reduction in glycated A1c of -0.11% (95% confidence interval, -0.16 to -0.06) each three months. In the continuous glucose monitoring user group, those who achieved more than 70% of time in range significantly increased from 3 months (37.4%) to 12 months (48.2%) (P < 0.001).

Conclusion

In this longitudinal study of type 1 diabetes mellitus adults, the use of continuous glucose monitoring for 1 year showed a significant reduction in glycated A1c in real-world practice.

Magnitude of Glycemic Improvement in Patients with Type 2 Diabetes Treated with Basal Insulin: Subgroup Analyses from the MOBILE Study

Objective: To determine if type 2 diabetes patients using basal insulin without prandial insulin with worse glycemic control at baseline would have the greatest benefit from using real-time continuous glucose monitoring (CGM). Methods: We conducted a post hoc analysis of the MOBILE Study, a multicenter trial examining the impact of CGM versus self-monitoring with a blood glucose meter (BGM) in patients with type 2 diabetes treated with basal insulin without prandial insulin. Participants were divided into subgroups based on baseline hemoglobin A1c (HbA1c) and baseline time-in-range 70-180 mg/dL (TIR). Change in TIR from baseline was calculated within each subgroup. Results: In subgroups based on baseline HbA1c, compared with the BGM group, the CGM group had 14% greater increase in TIR for participants with baseline HbA1c ≥8.5%, 14% greater increase for baseline HbA1c ≥9.0%, 22% greater increase for baseline HbA1c ≥9.5%, and 32% greater increase for baseline HbA1c ≥10.0% (P-value for interaction = 0.27). The time spent with glucose >250 mg/dL was significantly lower with CGM compared with BGM among participants with higher HbA1c values (P for interaction = 0.004). Results in subgroups based on baseline TIR paralleled the results in subgroups based on baseline HbA1c. Conclusion: While the benefit of CGM on TIR among patients with type 2 diabetes treated with basal insulin is apparent across the range of baseline glycemic control, the greatest impact of CGM is in those with the worst baseline glycemic control, particularly among those with HbA1c ≥10%. Clinical Trial Registration number: NCT03566693.

The Benefit of Insulin Degludec/Liraglutide (IDegLira) Compared With Basal-Bolus Insulin Therapy is Consistent Across Participant Subgroups With Type 2 Diabetes in the DUAL VII Randomized Trial

BACKGROUND

Insulin degludec/liraglutide (IDegLira) results in glycated hemoglobin (HbA1c) levels comparable with basal-bolus (BB) therapy. Here, we assessed the effect of once-daily IDegLira compared with BB (once-daily insulin glargine 100 U/mL and insulin aspart ≤4 times/day) across subgroups with varying characteristics.

MATERIALS AND METHODS

DUAL VII trial participants (type 2 diabetes [T2D], HbA1c 53-86 mmol/mol [7.0%-10.0%]) were subgrouped post hoc based on the following baseline characteristics: HbA1c (≤58.5, >58.5 to ≤69.4, and >69.4 mmol/mol; ≤7.5%, >7.5 to ≤8.5%, and >8.5%), body mass index (<30, ≥30 to <35, and ≥35 kg/m²), age (18 to <65 and ≥65 years), duration of diabetes (≥0 to 10 and ≥10 years), total pretrial daily basal insulin dose (20 to <30, ≥30 to <40, and ≥40 to ≤50 U), and fasting plasma glucose (<7.2 mmol/L/<130 mg/dL and ≥7.2 mmol/L/≥130 mg/dL).

RESULTS

Compared with BB, and in all subgroups, IDegLira treatment consistently gave similar HbA1c reductions, less severe or blood glucose-confirmed hypoglycemia, lower end-of-trial (EOT) total daily insulin dose, and weight loss. In all subgroups, mean EOT HbA1c was ≤53 mmol/mol (≤7.0%). The greatest HbA1c reduction occurred in the highest baseline HbA1c subgroup. Overall, mean EOT daily insulin dose was 0.43 to 0.52 U/kg with IDegLira and 0.74 to 1.07 U/kg with BB. More participants achieved the triple composite endpoint (HbA1c <53 mmol/mol [<7.0%] without weight gain or hypoglycemia) with IDegLira vs BB across the baseline HbA1c subgroups (≤58.5 mmol/mol [44.6% vs 7.0%], >58.5 to ≤69.4 mmol/mol [41.1% vs 8.3%], and >69.4 mmol/mol [23.8% vs 3.4%]).

CONCLUSION

These results support initiating IDegLira in patients with varying baseline characteristics and uncontrolled T2D on basal insulin.

CLINICALTRIALS.GOV REGISTRATION

NCT02420262.

Impact of Pharmacist-Led Drug Therapy Management Services on HbA1c Values in a Predominantly Hispanic Population Visiting an Outpatient Endocrinology Clinic

PURPOSE

To assess the impact pharmacists have on improving glycemic control among predominantly Hispanic diabetic patients visiting an endocrinology clinic in South Texas. Pharmacists were recently integrated into this clinic to be part of a collaborative team.

METHODS

This study follows a retrospective cohort design. All patients received diabetic care from endocrinologists, and some received pharmacist-led drug therapy management (PDTM). Patients with ≥1 PDTM were categorized as the intervention group and those without PDTM as the standard of care (SOC) group. The outcome variables were the mean absolute change in glycosylated hemoglobin (HbA_1c) from baseline and the proportion of patients at goal HbA_1c (<7%) postintervention.

RESULTS

Data were collected from 222 patients (n = 120 SOC patients, n = 102 PDTM patients). The mean age was 61 ± 14 years, 136 (61%) were female, and 197 (89%) were Hispanic. The mean absolute change in HbA_1c was -1.3%. In the adjusted model, the mean absolute change in HbA_1c in the PDTM compared to the SOC group was not significant (-0.1% ± 0.2%; P < .74), and concurrent interventions from registered dieticians (RDs) and licensed professional counselors (LPC) were identified as effect modifiers of the association. The stratum specific analysis identified the greatest decrease in HbA_1c when the three interventions (ie, PDTM, RD, and LPC) coincided (-1.0% ± 0.3%; P < .01). Postintervention, 25% of those who received PDTM achieved an HbA_1c<7% as compared to 19% in the SOC group.

CONCLUSION

The clinical importance of pharmacists is enhanced when integrated with behavioral modifying programs to achieve additional improvement in HbA_1c.

Use of Dapagliflozin in the Management of Type 2 Diabetes Mellitus: A Real-World Evidence Study in Indian Patients (FOREFRONT)

Background: Dapagliflozin is approved in India based on a controlled clinical study. This study included type 2 diabetes mellitus (T2DM) Indian patients to determine effectiveness of dapagliflozin in the real-world setup. Methods: Data were collected retrospectively and prospectively for 3 months. Primary endpoint was mean change in glycated hemoglobin (HbA1c) from baseline to months 3 and 6. Patients were stratified by baseline HbA1c and body mass index (BMI). Paired t-test or Wilcoxon signed-rank test at 5% level of significance with two-sided 95% confidence intervals analyzed endpoints. Results: Total 98.1% (n = 1941/1978) patients completed the study, majority of them were men (57.5%), <60 years (77.8%). Mean (standard deviation [SD]) HbA1c decreased significantly from baseline (9.11% [1.44]) to month 3 (8.11% [1.22]; Δ = 1.00% [1.01]) and month 6 (7.62% [1.04]; Δ = 1.49% [1.18]), P < 0.001. Per baseline HbA1c stratification, the largest mean (SD) decrease in HbA1c was in patients with baseline HbA1c >10% (1.86% [1.32] at month 3; 2.80% [1.22] at month 6). Decrease in mean body weight was significant from baseline (78.15 kg [13.48]) to month 3 (77.01 kg [13.21]; Δ = 1.14 kg [2.21]) and month 6 (76.16 kg [13.09]; Δ = 1.86 kg [3.04]), P < 0.001, with maximum weight loss in patients with BMI >30 kg/m² (1.60 kg [2.50] and 2.56 kg [3.50] at months 3 and 6, respectively). Systolic/diastolic blood pressure also improved. Of the 58 (2.9%) patients having ≥1 adverse event (AE), 9 (0.5%) had vulvovaginitis and 4 (0.2%) each had fungal infection and urinary tract infection (UTI). One patient had a serious AE (SAE) of UTI. No patients died or discontinued the study because of AEs or SAEs. Conclusion: Dapagliflozin significantly decreased HbA1c and body weight in Indian T2DM patients. Dapagliflozin was well tolerated and no new safety signals were detected.

Change in HbA1c Across the Baseline HbA1c Range in Type 2 Diabetes Patients Receiving Once-Weekly Dulaglutide Versus Other Incretin Agents

INTRODUCTION

This exploratory post hoc analysis investigated the relative changes in glycated haemoglobin (HbA_1c) in patients with type 2 diabetes mellitus (T2DM) treated with dulaglutide versus active comparators across a continuous range of baseline HbA_1c values using data from three phase III randomised controlled trials.

METHODS

Data from patients receiving once-weekly dulaglutide 0.75 and 1.5 mg, once-daily sitagliptin 100 mg, once-daily liraglutide 1.8 mg or twice-daily exenatide 10 μg in the intent-to-treat populations in the AWARD-5, AWARD-6 and AWARD-1 trials were analysed using last observation carried forward analysis of covariance. Starting with the predefined statistical model from each study, the type of association between HbA_1c baseline and change at 26 weeks was modelled. Consistency of treatment effect was assessed via treatment-by-baseline HbA_1c interaction terms.

RESULTS

Improvements in HbA_1c occurred in all treatment groups across the entire baseline HbA_1c range. The relationship between HbA_1c baseline and magnitude of change was linear in all treatment groups, with greater reductions in patients with higher baseline HbA_1c values. Across the continuum of baseline HbA_1c values, patients treated with dulaglutide 1.5 mg achieved a similar mean HbA_1c reduction to patients receiving liraglutide 1.8 mg and a greater reduction than patients receiving twice-daily exenatide or sitagliptin. In AWARD-5, the treatment-by-baseline HbA_1c interaction P value (0.001) demonstrated progressively greater HbA_1c reduction in dulaglutide-treated compared with sitagliptin-treated patients as baseline HbA_1c increased.

CONCLUSION

Our results suggest that dulaglutide is an appropriate therapeutic option for patients with T2DM across a wide range of baseline HbA_1c values, including those with poor metabolic control.

FUNDING

Eli Lilly and Company. Plain language summary available for this article.

A multicentre, UK, retrospective, observational study to assess the effectiveness of insulin glargine 300 units/ml in treating people with Type 1 diabetes mellitus in routine clinical practice (SPARTA)

AIM

To conduct an open-label study to provide UK real-world evidence regarding the use of insulin glargine 300 units/ml (U300) in people with Type 1 diabetes mellitus.

METHODS

People with Type 1 diabetes who had been prescribed U300 ≥6 months before data collection and had HbA_1c levels recorded within 3 months prior to U300 (baseline) were included. The primary endpoint was change in HbA_1c from baseline to month 6 after U300 initiation. Other endpoints included number of documented hypoglycaemic and diabetic ketoacidosis episodes, and change in daily basal insulin dose.

RESULTS

A total of 298 people with Type 1 diabetes were included [mean age 42.1 years, mean HbA_1c 79 mmol/mol (9.4%)]. After U300 initiation, the mean reduction in HbA_1c from baseline to month 6 was -4 mmol/mol (-0.4%; P<0.001; n=188). The total daily basal insulin dose at 6 months was 1.3 units higher than at the time of U300 initiation (P<0.001; n=275) but was not significantly different from the prior basal insulin dose. There was no clinically significant difference in weight between baseline and month 6 [mean difference +0.7 kg, 95% CI -0.1, 1.5; P=0.084; n=115). During the 6 months before and after U300 initiation, severe hypoglycaemic episodes were documented for 6/298 and 4/298 participants. Diabetic ketoacidosis episodes requiring Accident and Emergency department visits or hospitalization were documented for 4/298 and 6/298 participants, before and after U300 initiation, respectively.

CONCLUSIONS

In people with Type 1 diabetes, a change in basal insulin to U300 was associated with clinically and statistically significant HbA_1c improvements, without significant changes in basal insulin dose and weight. Documented severe hypoglycaemia episodes and diabetic ketoacidosis requiring Accident and Emergency department visits or hospitalization were low and similar before and after U300 initiation.

Integrated personalized diabetes management improves glycemic control in patients with insulin-treated type 2 diabetes: Results of the PDM-ProValue study program

AIMS

Globally, many patients with insulin-treated type-2 diabetes are suboptimally controlled. The PDM-ProValue study program evaluated whether integrated personalized diabetes management (iPDM) has the potential to improve clinical outcomes.

METHODS

101 practices with 907 patients participated in the 12-month, prospective, controlled, cluster-randomized study program. HbA1c levels, therapy changes, frequency of hypoglycemic episodes, patient reported outcomes, and physician satisfaction were assessed.

RESULTS

iPDM led to a greater reduction in HbA1c after 12 months vs. usual care (-0.5%, p < 0.0001 vs. -0.3%, p < 0.0001), (Diff. 0.2%, p = 0.0324). Most of the HbA1c reduction occurred after 3 months and remained stable thereafter. The percentage of patients with therapy adjustments was higher in the iPDM group at all visits (p < 0.01 at week 3, month 3, month 6). Patient adherence at month 12 was higher in the iPDM group compared to baseline (Odds ratio = 2.39; p = 0.0003); also, patient treatment satisfaction (DTSQc: 12.2 vs. 10.4, δ = 1.78, p = 0.004; DTSQs: 31.0 vs. 30.0, δ = 0.924, p = 0.02), and physician satisfaction was higher in the intervention group.

CONCLUSIONS

iPDM improved the use of diagnostic data leading to better glycemic control, more timely treatment adjustments (indicating reduced clinical inertia), and increased patient adherence and treatment satisfaction among patients and physicians.

Baseline Glycated Hemoglobin Values Predict the Magnitude of Glycemic Improvement in Patients with Type 1 and Type 2 Diabetes: Subgroup Analyses from the DIAMOND Study Program

The DIAMOND study demonstrated that the addition of real-time continuous glucose monitoring (rtCGM) effectively lowers glycated hemoglobin (HbA_1c) in patients with type 1 (T1D) and type 2 diabetes (T2D), treated with multiple daily injections (MDI). This post hoc analysis investigated whether DIAMOND study participants at progressively higher baseline HbA_1c levels benefit from using rtCGM. We examined outcomes data from a large, randomized, controlled trial of MDI-treated participants with T1D (N = 158) and T2D (N = 158), comparing monitoring by rtCGM versus self-monitoring of blood glucose (SMBG). The primary outcome was the magnitude of HbA_1c reductions among study participants within elevated baseline HbA_1c levels (≥8.0%-10.0%, ≥8.5%-10.0%, and ≥9.0%-10.0%). Analyses were performed on three subgroups: T1D, T2D, and combined T1D/T2D. The full T1D analysis population had a mean baseline HbA_1c value of 8.6 ± 0.6% (range 7.5%-9.9%), randomized to rtCGM (n = 105) or control (n = 53). The full T2D analysis population had a mean baseline HbA_1c value of 8.5 ± 0.6% (range 7.5%-9.9%), randomized to rtCGM (n = 79) or control (n = 79). Participants had improvements in glycemic status regardless of monitoring method. In the three subgroups, the change in HbA_1c was significantly greater in rtCGM participants compared to SMBG at all predefined baseline HbA_1c levels at 12 and 24 weeks. Among the rtCGM participants, the change in HbA_1c was numerically greatest at the highest baseline HbA_1c subgroup (≥9.0%). Participants with elevated baseline HbA_1c had improvements in glycemic status regardless of monitoring method. However, the magnitudes of improvements appeared greater among participants using rtCGM.

Effects of exenatide twice daily, exenatide once weekly or insulin in patients with type 2 diabetes and baseline HbA1c ≥10.0%: Two pooled analyses including 20 randomised controlled trials

AIMS

Patients with advanced type 2 diabetes (T2D) and high glycated haemoglobin (HbA1c) values can be difficult to treat because of their severe metabolic disease. This pooled analysis examined the treatment effects of exenatide twice daily (BID), exenatide once weekly (QW) and insulin in patients with high baseline HbA1c (≥10.0%).

METHODS

This post hoc analysis used pooled data from 12 and 8 randomised controlled trials of exenatide BID and exenatide QW, respectively. Patients with T2D who completed at least 24 weeks of treatment with exenatide BID, exenatide QW or insulin (insulin glargine, insulin detemir or insulin aspart) were categorised by baseline HbA1c. Patients with HbA1c ≥10.0% were included in the analysis.

RESULTS

Both exenatide and insulin reduced HbA1c (mean ± SE reduction: -2.0% ± 0.2% [exenatide] and -2.1% ± 0.2% [insulin] in the exenatide BID studies, and -2.6% ± 0.1% [exenatide] and -2.1% ± 0.2% [insulin] in the exenatide QW studies; all P < .001). Body weight decreased with exenatide and increased with insulin. Systolic blood pressure decreased with exenatide QW. Insulin dose increased over the course of treatment. The most common adverse events with exenatide were gastrointestinal. Insulin was associated with some hypoglycaemia risk. Hypoglycaemia events occurred infrequently with exenatide when given without sulphonylureas.

CONCLUSIONS

For patients with high HbA1c, treatment with exenatide or insulin both improved glycaemic control. Given the associated weight loss and low risk of hypoglycaemia, exenatide may be a suitable alternative to treatment with insulin in certain patients with T2D and high HbA1c.

Glycemic excursions are positively associated with HbA1c reduction from baseline after treatment with acarbose in patients with type 2 diabetes on metformin monotherapy

BACKGROUND

The aim of the present study was to examine the association between glycemic excursions before treatment and HbA1c reduction after treatment intensification with acarbose or glibenclamide in patients with type 2 diabetes (T2D).

METHODS

Patients receiving single or dual oral antidiabetic drug treatment with an HbA1c of 7.0-11.0 % (53-97 mmol/mol) were switched to metformin monotherapy (500 mg, t.i.d.) for 8 weeks, followed by randomization to either acarbose (100 mg, t.i.d.) or glibenclamide (5 mg, t.i.d.) as add-on treatment for 16 weeks. Glycemic excursions were assessed as mean amplitude of glycemic excursions (MAGE) with 72-h ambulatory continuous glucose monitoring. Treatment efficacy was evaluated as relative HbA1c reduction (%), calculated as (baseline HbA1c - post-treatment HbA1c)/baseline HbA1c × 100.

RESULTS

Fifty patients (mean [±SD] age 53.5 ± 8.2 years, 48 % men, mean baseline HbA1c 8.4 ± 1.2 %) were analyzed. Baseline MAGE was positively correlated with relative HbA1c reduction from baseline in patients treated with acarbose (r = 0.421, P = 0.029) but not glibenclamide (r = 0.052, P = 0.813). Linear regression analysis revealed that the association between baseline MAGE and relative HbA1c reduction from baseline (β = 0.125, P = 0.029) in patients treated with acarbose remained significant after adjustment for several confounders (P < 0.05 for all models).

CONCLUSIONS

In patients with T2D on metformin monotherapy, baseline MAGE was positively correlated with relative HbA1c reduction from baseline after treatment with acarbose, but not glibenclamide. These findings highlight the importance of glycemic excursions in individualized treatment for patients with T2D.

Should Studies of Diabetes Treatment Stratification Correct for Baseline HbA1c?

Aims

Baseline HbA1c is a major predictor of response to glucose lowering therapy and therefore a potential confounder in studies aiming to identify other predictors. However, baseline adjustment may introduce error if the association between baseline HbA1c and response is substantially due to measurement error and regression to the mean. We aimed to determine whether studies of predictors of response should adjust for baseline HbA1c.

Methods

We assessed the relationship between baseline HbA1c and glycaemic response in 257 participants treated with GLP-1R agonists and assessed whether it reflected measurement error and regression to the mean using duplicate ‘pre-baseline’ HbA1c measurements not included in the response variable. In this cohort and an additional 2659 participants treated with sulfonylureas we assessed the relationship between covariates associated with baseline HbA1c and treatment response with and without baseline adjustment, and with a bias correction using pre-baseline HbA1c to adjust for the effects of error in baseline HbA1c.

Results

Baseline HbA1c was a major predictor of response (R² = 0.19,β = -0.44,p<0.001).The association between pre-baseline and response was similar suggesting the greater response at higher baseline HbA1cs is not mainly due to measurement error and subsequent regression to the mean. In unadjusted analysis in both cohorts, factors associated with baseline HbA1c were associated with response, however these associations were weak or absent after adjustment for baseline HbA1c. Bias correction did not substantially alter associations.

Conclusions

Adjustment for the baseline HbA1c measurement is a simple and effective way to reduce bias in studies of predictors of response to glucose lowering therapy.

Insulin degludec/liraglutide (IDegLira) for the treatment of type 2 diabetes

The progressive nature of type 2 diabetes necessitates that treatment is intensified as the disease advances. Several studies have shown that basal insulin and glucagon-like peptide-1 receptor agonists (GLP-1RAs) can be used in combination to successfully improve glycemic control and this combination is increasingly being considered as an alternative to intensification with prandial insulin. Insulin degludec/liraglutide (IDegLira) is the first fixed-ratio combination of a basal insulin and a GLP-1RA in a single formulation. Here we consider the benefits and potential limitations of such a combination, focusing on the unique modes of action of insulin degludec and the once-daily GLP-1RA liraglutide. IDegLira offers an efficacious combination therapy (mean end-of-trial HbA_1c was 6.4-6.9% across the five completed Phase 3 trials), which was well-tolerated in clinical trials. The complementary modes of action resulted in a low rate of hypoglycemia and no weight gain in insulin-treated patients. As a once-daily injection with effects on both fasting and post prandial hyperglycemia, IDegLira has the potential to help many patients reach glycemic target (60-81% of patients achieved HbA_1c <7% in clinical trials).

Impact of telephonic interviews on persistence and daily adherence to insulin treatment in insulin-naïve type 2 diabetes patients: dropout study

OBJECTIVE

The objective of this study is to evaluate the impact of sequential telephonic interviews on treatment persistence and daily adherence to insulin injections among insulin-naïve type 2 diabetes patients initiated on different insulin regimens in a 3-month period.

METHODS

A total of 1,456 insulin-naïve patients with type 2 diabetes (mean [standard deviation, SD] age: 56.0 [12.0] years, 49.1% were females) initiated on insulin therapy and consecutively randomized to sequential (n=733) and single (n=723) telephonic interview groups were included. Data on insulin treatment and self-reported blood glucose values were obtained via telephone interview. Logistic regression analysis was performed for factors predicting increased likelihood of persistence and skipping an injection.

RESULTS

Overall, 76.8% patients (83.2% in sequential vs 70.3% in single interview group, (P<0.001) remained on insulin treatment at the third month. Significantly higher rate for skipping doses was noted in basal bolus than in other regimens (27.0% vs 15.0% for premixed and 15.8% basal insulin, respectively, P<0.0001). Logistic regression analysis revealed sequential telephonic interview (odds ratio [OR], 1.531; 95% confidence interval [CI], 1.093-2.143; P=0.013), higher hemoglobin A1c levels (OR, 1.090; 95% CI, 0.999-1.189; P=0.049), and less negative appraisal of insulin therapy as significant predictors of higher persistence. Basal bolus regimen (OR, 1.583; 95% CI, 1.011-2.479; P=0.045) and higher hemoglobin A1c levels (OR, 1.114; 95% CI, 1.028-1.207; P=0.008) were the significant predictors of increased likelihood of skipping an injection.

CONCLUSION

Our findings revealed positive influence of sequential telephonic interview, although including no intervention in treatment, on achieving better treatment persistence in type 2 diabetes patients initiating insulin.

Glycosylated hemoglobin level and number of oral antidiabetic drugs predict whether or not glycemic target is achieved in insulin-requiring type 2 diabetes

AIMS

Factors predicting success (glycosylated hemoglobin (A1C)<7%) with insulin therapy in patients with insulin-requiring type 2 diabetes need to be identified.

METHODS

A retrospective, multi-center, observational study was conducted for outpatients with oral antidiabetic drug (OAD)-treated type 2 diabetes whose A1C levels remained above 7%. Patients were begun on basal insulin between January 2005 and December 2006. Biochemical variables and demographic data were collected before and after 52 weeks of insulin therapy.

RESULTS

A total of 565 patients (age, 60.4±11.9 years; A1C levels, 10.11 ±1.81%; duration of diabetes, 11.5±6.8 years) were studied. By study end, 63 patients (11.2%) had achieved the glycemic goal (A1C<7%). The glycemic goal attainment rate was only 9.1% in patients with A1C>8.8% and who were taking >2 OADs at baseline. The highest rate (32.7%) of successful glycemic control was observed in the group of patients with A1C ≤ 8.8% and who used ≤ 2 OADs at baseline.

CONCLUSIONS

Insulin-naïve diabetic patients with A1C>8.8%, especially those who are taking >2 OADs, have small chance to achieve good glycemic control with adding only basal insulin therapy.

Comparison of insulin glargine and liraglutide added to oral agents in patients with poorly controlled type 2 diabetes

AIM

To compare safety and efficacy of insulin glargine and liraglutide in patients with type 2 diabetes (T2DM).

METHODS

This randomized, multinational, open-label trial included subjects treated for T2DM with metformin ± sulphonylurea, who had glycated haemoglobin (HbA1c) levels of 7.5-12%. Subjects were assigned to 24 weeks of insulin glargine, titrated to target fasting plasma glucose of 4.0-5.5 mmol/L or liraglutide, escalated to the highest approved clinical dose of 1.8 mg daily. The trial was powered to detect superiority of glargine over liraglutide in percentage of people reaching HbA1c <7%.

RESULTS

The mean [standard deviation (s.d.)] age of the participants was 57 (9) years, the duration of diabetes was 9 (6) years, body mass index was 31.9 (4.2) kg/m(2) and HbA1c level was 9.0 (1.1)%. Equal numbers (n = 489) were allocated to glargine and liraglutide. Similar numbers of subjects in both groups attained an HbA1c level of <7% (48.4 vs. 45.9%); therefore, superiority of glargine over liraglutide was not observed (p = 0.44). Subjects treated with glargine had greater reductions of HbA1c [-1.94% (0.05) and -1.79% (0.05); p = 0.019] and fasting plasma glucose [6.2 (1.6) and 7.9 (2.2) mmol/L; p < 0.001] than those receiving liraglutide. The liraglutide group reported a greater number of gastrointestinal treatment-emergent adverse events (p < 0.001). The mean (s.d.) weight change was +2.0 (4.0) kg for glargine and -3.0 (3.6) kg for liraglutide (p < 0.001). Symptomatic hypoglycaemia was more common with glargine (p < 0.001). A greater number of subjects in the liraglutide arm withdrew as a result of adverse events (p < 0.001).

CONCLUSION

Adding either insulin glargine or liraglutide to subjects with poorly controlled T2DM reduces HbA1c substantially, with nearly half of subjects reaching target levels of 7%.

Estimating Cost-Effectiveness in Type 2 Diabetes: The Impact of Treatment Guidelines and Therapy Duration

OBJECTIVES

Type 2 diabetes mellitus (T2DM) clinical guidelines focus on optimizing glucose control, with therapy escalation classically initiated within a "failure-based" regimen. Within many diabetes models, HbA1c therapy escalation thresholds play a pivotal role, controlling duration of therapy and, consequently, incremental costs and benefits. The objective of this study was to assess the relationship between therapy escalation threshold and time to therapy escalation on predicted cost-effectiveness of T2DM treatments.

METHODS

This study used the Cardiff Diabetes Model to illustrate the relationship between costs and health outcomes associated with first-, second-, and third-line therapy as a function of time on each. Data from routine clinical practice were used to contrast predicted costs and health outcomes associated with guideline therapy escalation thresholds compared with clinical practice. The impact of baseline HbA1c and therapy escalation thresholds on cost-effectiveness was investigated, comparing a sodium/glucose cotransporter 2 inhibitor v. sulfonylurea added to metformin monotherapy.

RESULTS

Lower thresholds are associated with a shorter time spent on monotherapy, ranging from 1.1 years (escalation at 6.5%) to 13 years (escalation at 9.0%) and an increase in total lifetime cost of therapy. Treatment-related disutility is minimized with higher thresholds because progression to insulin is delayed. Using metformin combined with either dapagliflozin or a sulfonylurea to illustrate lower baseline HbA1c and/or higher therapy escalation thresholds was associated with increased cost-effectiveness ratios, driven by a longer duration of therapy.

DISCUSSION

A marked difference in treatment cost-effectiveness was demonstrated when comparing routine clinical practice with guideline-advocated therapy escalation. This is important to both health care professionals and the wider health economic community with respect to understanding the true cost-effectiveness profile of any particular T2DM therapy option.

Metabolic effects of Basal or premixed insulin treatment in 5077 insulin-naïve type 2 diabetes patients: registry-based observational study in clinical practice

INTRODUCTION

To investigate the clinical effects associated with premixed insulin (PM) and basal insulin [insulin NPH (NPH), insulin glargine (IG), insulin detemir (ID)], in insulin-naïve patients with type 2 diabetes in routine clinical care.

MATERIALS AND METHODS

Cohort study based on data from the Swedish National Diabetes Register, including 5,077 patients, resident in the Western region of Sweden. Patients were included between 1 July 2006 and 31 December 2009 and followed for 12 months. Changes in HbA1c, body mass index (BMI) and required insulin doses were compared between the different insulin types. Covariance adjustments were performed to adjust for differences between the groups.

RESULTS

NPH, IG, ID and PM were all associated with significant reductions in HbA1c, mean ± standard deviation ranged between 6.6 ± 17.4 mmol/mol (IG) and 8.9 ± 17.7 mmol/mol (NPH), during the 12 months of follow-up. There were no statistically significant differences in the magnitude of HbA1c reduction between the insulin types. PM required 59% higher and ID 25% higher insulin doses to achieve a similar HbA1c reduction as NPH. PM was associated with a significantly greater increase in BMI compared with NPH (p = 0.016), while IG and ID did not differ significantly from NPH. The number of patients experiencing severe hypoglycemia was low, but highest in patients treated with PM (p = 0.023).

CONCLUSIONS

NPH, IG, ID and PM were found to be equally effective in lowering HbA1c in insulin-naïve patients with type 2 diabetes in routine clinical care in Sweden. The effects on weight, dose and treatment persistence support the recommendation of NPH or IG as first and second choices in this group of patients requiring initiation of insulin treatment.

Effect of baseline glycosylated hemoglobin A1c on glycemic control and diabetes management following initiation of once-daily insulin detemir in real-life clinical practice

OBJECTIVE

The SOLVE study investigated the initiation of basal insulin in patients with type 2 diabetes on oral antidiabetic (OAD) treatment and outcomes in patients with varying levels of glycemic control at baseline.

METHODS

This was an observational cohort study conducted in 10 countries using insulin detemir. Data were collected at 3 clinic visits (baseline, 12-week interim, and 24-week final visit).

RESULTS

A total of 13,526 (77.9%) patients were included in the glycosylated hemoglobin A1c (HbA1c) subset analysis. Patients were grouped according to pre-insulin HbA1c values as follows: HbA1c <7.6% (n = 2,797); HbA1c 7.6-9% (n = 5,366), and HbA1c >9% (n = 5,363). A total of 27 patients experienced serious adverse drug reactions (SADRs) and/or severe hypoglycemia (3, 10, and 11 patients with pre-insulin HbA1c <7.6%, 7.6-9.0%, and >9.0%, respectively). All patient subgroups realized improvements in HbA1c, with the pre-insulin HbA1c >9% subgroup having the largest HbA1c reduction (-2.4% versus -0.9% and -0.2% for HbA1c subgroups 7.6-9% and <7.6%, respectively). In the total cohort (n = 17,374), the incidence of severe hypoglycemia decreased from 4 events per 100 person years to <1 event per 100 person years by final visit; the incidence of minor hypoglycemia increased from 1.6 to 1.8 events per person year.

CONCLUSIONS

In this study, insulin initiation was delayed until late in disease course, and overall concordance with internationally recognized guidelines was low. The initiation of once-daily insulin detemir was associated with substantial improvements in glycemic control and was not associated with an increase in severe hypoglycemia or weight gain.

Predictive and explanatory factors of change in HbA1c in a 24-week observational study of 66,726 people with type 2 diabetes starting insulin analogs

OBJECTIVE

Individualization of therapy choices requires the prediction of likely response. Predictor and explanatory factors of change in HbA1c were studied using data from a large observational study of starting insulin analog therapy (the A1chieve study).

RESEARCH DESIGN AND METHODS

Univariate analyses were performed for insulin-naive people and prior insulin users in the A1chieve study. Statistically significant factors were carried forward to baseline factor-only multivariate analyses ("predictor" analysis), and separately using all significant factors ("explanatory" analysis). Power was considered in terms of the variance explained.

RESULTS

Geographical region, baseline HbA1c level, lipid levels, and baseline insulin dose were the most powerful predictors of HbA1c change (mean change -2.1% [-23 mmol/mol]) observed in the univariate analysis (r2 > 0.010, P < 0.001). However, although the predictor and explanatory multivariate models explained 62-82% of the variance in HbA1c change, this was mainly associated with baseline HbA1c (r2 = 0.544-0.701) and region (r2 = 0.014-0.037). Other factors were statistically significant but had low predictive power (r2 < 0.010); in the explanatory analysis, this included end-of-study hypoglycemia (insulin-naive group), insulin dose, and health-related quality of life (r(2) < 0.001-0.006, P ≤ 0.007).

CONCLUSIONS

Many factors can guide clinicians in predicting the response to starting therapy with insulin analogs, but many are interdependent and thus of poor utility. The factor explaining most of the variance in HbA1c change is baseline HbA1c level, with each increase of 1.0%-units (11 mmol/mol) providing a 0.7-0.8%-units (8-9 mmol/mol) greater fall. Other factors do not explain much of the remaining variance, even when including all end-of-trial measures.

Post-meal β-cell function predicts the efficacy of glycemic control in patients with type 2 diabetes inadequately controlled by metformin monotherapy after addition of glibenclamide or acarbose

BACKGROUND

This study aimed to explore parameters which will predict good control of HbA1c after adding a second anti-diabetic drug in patients with type 2 diabetes mellitus (T2DM) inadequately controlled with metformin monotherapy.

METHODS

Fifty-one patients (M/F: 25/26, mean age: 53.7 ± 8.2 years, mean glycated hemoglobin [HbA1c] 8.4 ± 1.2%) with T2DM inadequately controlled with metformin were randomized to add-on glibenclamide or acarbose for 16 weeks. Before and after combination therapy, the subjects underwent a 2-hour liquid mixed meal tolerance test to determine insulin secretion (HOMA-β, insulinogenic index, and disposition index [DI]) and insulin sensitivity (HOMA-IR and Matsuda insulin sensitivity index).

RESULTS

At baseline, there was a significant inverse relationship between DI120 and HbA1c (p = 0.001) in all subjects. The addition of glibenclamide and acarbose improved HbA1c significantly from 8.6 ± 1.6% to 7.4 ± 1.2% (p < 0.001), and from 8.2 ± 0.8% to 7.5 ± 0.8% (p < 0.001), respectively. In the glibenclamide group, DI120 significantly increased from 51.2 ± 24.2 to 74.9 ± 41.9 (p < 0.05), and in the acarbose group, from 62.5 ± 31.4 to 91.7 ± 36.2 (p < 0.05), respectively. Multiple regression analyses showed that both baseline HbA1c and DI120 independently predicted reduction of HbA1c as well as final HbA1c after combination therapy.

CONCLUSIONS

In patients with T2DM inadequately controlled with metformin, add-on oral anti-diabetic agent with glibenclamide or acarbose resulted in the significant HbA1c reduction and improvement of β-cell function. Subjects with greater baseline β-cell function reserve displayed better glycemic response in the combination therapy of metformin with glibenclamide or acarbose.

TRIAL REGISTRATION

This study was registered in the ClinicalTrials.gov with registration number of NCT00417729.