Individualized Treatment of Type 2 Diabetes Mellitus Using Noninsulin Agents: Clinical Considerations for the Primary Care Physician

Factors of primary and secondary sulfonylurea failure in type 2 diabetic subjects

BACKGROUND

The aim of the present study was to investigate the value of clinical characteristics in predicting sulfonylurea (SU) treatment responses.

METHODS

All 747 subjects in the present study were from the Xiaoke Pill Clinical Trial evaluating the safety and efficacy of SU. Subjects had the same initial dose of glibenclamide and drug doses were adjusted every 4 weeks during the 48-week follow-up period. Primary SU failure was defined as a <10% reduction in fasting plasma glucose (FPG) at the end of Week 4 from randomization, whereas secondary SU failure was defined as a consecutive confirmed level of FPG >7 mmol/L.

RESULTS

Kaplan-Meier survival analysis revealed that lower baseline basal disposition index (DI _b ) and higher FPG predict secondary SU failure. Inversely, higher baseline DI _b and lower FPG predict primary SU failure. Primary SU failure can predict secondary SU failure. The combination of lower baseline DI _b with primary SU failure is a better predictor of secondary SU failure than lower baseline DI _b or primary SU failure alone.

CONCLUSIONS

Patients with good glycemic control and higher β-cell reserve at entry are more likely to experience primary SU failure but are less likely to experience secondary SU failure. By combining baseline DI _b with initial response at the first month of treatment, we can get quick information about the long-term efficacy of SU treatment.

Efficacy and safety of linagliptin according to patient baseline characteristics: A pooled analysis of three phase 3 trials

BACKGROUND AND AIMS

We aimed to determine if patient baseline characteristics affect responses to linagliptin and identify relevant predictors of glycated hemoglobin (HbA1c) reduction in patients with type 2 diabetes mellitus (T2DM).

METHODS AND RESULTS

Data were pooled from three 24-week, placebo-controlled trials of similar design (linagliptin, n = 1651; placebo, n = 607). Patients were categorized according to baseline characteristics: age, T2DM duration, gender, body mass index (BMI), Homeostasis Model Assessment of Insulin Resistance (HOMA-IR), and metabolic syndrome (MetS). Changes from baseline in HbA1c after 24 weeks were assessed with analysis of covariance (ANCOVA). The proportion of patients with baseline HbA1c >7% achieving HbA1c of ≤7% at week 24 were evaluated. Independent predictors of HbA1c response with linagliptin were analyzed in a multivariate analysis with ANCOVA. Linagliptin treatment led to significant mean (SE) placebo-corrected reductions from baseline in HbA1c across all subgroups (-0.42% [±0.11] to -0.79% [0.08]; all p < 0.001). Within subgroups, HbA1c reduction was more pronounced in patients without MetS (-0.74% [0.06]; treatment interaction p = 0.0489). The proportion of patients with baseline HbA1c >7% achieving a target HbA1c ≤7% was greater with linagliptin versus placebo (30.2% vs 11.5%; odds ratio 3.82; 95% CI 2.82 to 5.17; p < 0.001). Characteristics significantly predicting HbA1c reductions after 24 weeks were fasting plasma glucose and race (both p < 0.05).

CONCLUSION

This post-hoc analysis supports that linagliptin achieved clinically meaningful improvements in hyperglycemia in patients with diverse clinical characteristics. These improvements were more pronounced in patients without MetS.

Effectiveness and safety of glimepiride and iDPP4, associated with metformin in second line pharmacotherapy of type 2 diabetes mellitus: systematic review and meta-analysis

OBJECTIVE

Our review analyses the studies that have specifically compared the association iDPP4/metformin with glimepiride/metformin, both in second line pharmacotherapy of type 2 diabetes mellitus (DM2).

METHODS

Systematic literature review with a meta-analysis of clinical trials comparing glimepiride with any iDPP4, both used together with metformin as a second line treatment of DM2. The effectiveness variables used were as follows: %HbA1c variation, fasting plasma glucose variation, patients achieving the therapeutic objective of HbA1c <7%, treatment dropouts due to lack of effectiveness and rescue treatments needed. The safety variables included were as follows: weight variation at the end of treatment; presentation of any type of adverse event; presentation of serious adverse events; patients who experienced any type of hypoglycaemia; patients who experienced severe hypoglycaemia; treatments suspended due to adverse effects; and deaths for any reason.

RESULTS

Four studies met the inclusion criteria. The group treated with glimepiride showed better results in all effectiveness variables. Regarding safety variables, the main differences observed were in the greater number of cases with hypoglycaemia in the group treated with glimepiride, and the serious adverse events or treatment discontinuations due to these which occurred in slightly over 2% more cases in this group compared to the iDPP4 group. The remaining adverse events, including mortality, did not show any differences between both groups. The variation in the weight difference between groups (2.1 kg) is not considered clinically relevant.

CONCLUSIONS

A greater effectiveness is seen in the glimepiride/metformin association, which should not be diminished by slight differences in adverse effects, with absence of severe hypoglycaemia in over 98% of patients under treatment. The association of glimepiride/metformin, both due to cost as well as effectiveness and safety, may be the preferential treatment for most DM2 patients, and it offers a potential advantage in refractory hyperglycemic populations, tolerant to treatment.

Application of clinical judgment and guidelines to achieving glycemic goals in type 2 diabetes: focus on pharmacologic therapy

Successful management of patients with type 2 diabetes mellitus requires attention to 4 pillars of care: diet, exercise, blood glucose monitoring, and pharmacologic therapy. For pharmacologic therapy, the availability of multiple drugs in different classes can make choices regarding initiation and intensification of treatment challenging. This article, focusing on clinical practice, reviews and provides guidance on assessing recommendations made by the latest diabetes guidelines for pharmacotherapy published by the American Diabetes Association and the American Academy of Clinical Endocrinologists. The article discusses how diabetes guidelines evolved, their move toward personalization of therapy, and their effective use in clinical practice. An appraisal of various pharmacologic strategies is integrated with the author's approach to achieving glycemic goals with a minimum of weight gain or hypoglycemic episodes. Using patients' baseline glycated hemoglobin levels and the degree to which their fasting and postprandial plasma levels contribute to their hyperglycemia is explained as a strategy by which drugs can be chosen that act on these parameters. Lifestyle interventions such as diet and exercise should continue to form the foundation of the therapeutic alliance between the clinician and patient as pharmacologic therapy is initiated or intensified.