Reduced tissue sodium content is related to improvement of vascular function in patients with chronic heart failure treated with the SGLT2 inhibitor empagliflozin

Background

Large randomized controlled trials have demonstrated that SGLT2 inhibitors produce cardiovascular benefits beyond their metabolic effects. One of the assumed underlying mechanisms is the reduction of the left ventricular afterload. Factors aggravating the afterload are impaired vascular function (ventricular-arterial coupling) as well as high tissue sodium content, which exerts enhanced hypertrophic stimuli and exaggerated response to vasoconstrictors.

Purpose

We hypothesized that the SGLT2 inhibitor empagliflozin leads to afterload reduction in patients with chronic heart failure (CHF) by reducing tissue sodium content and improving vascular function and that these changes are related to each other.

Methods

In a randomized (2:1), investigator initiated, double-blind, placebo controlled, parallel-group, prospective clinical study, patients with CHF NYHA II-III and an ejection fraction of 49% or less were randomized to empagliflozin 10mg once daily or placebo. In each patient, we assessed vascular parameters under resting conditions (Sphygmocor) and 24-hour daily life conditions (Mobilograph), including central systolic pressure (cSBP) and central pulse pressure (cPP) among others. In parallel, we measured tissue (skin and muscle) sodium content of the lower leg by Sodium-MRI, at baseline and after 1 month of therapy.

Results

A total of 74 patients (men: n=62), aged 66±9 years, with a mean ejection fraction of 39±9% were included. Only 24% of the patients had type 2 diabetes. After 1 month treatment with empagliflozin, a decrease of skin sodium content was observed (22.8±6.1 vs. 21.6±6.0 mmol/l, p=0.039), while there was no significant change in muscle sodium and muscle water content. A decrease of cSBP (117.1±14.5 vs. 110.7±11.3 mmHg, p<0.001) and cPP (41.4±8.8 vs. 38.4±8.5 mmHg, p=0.004) under resting conditions was observed after 1 month treatment with empagliflozin, while changes in the placebo group were not significant for cSBP (117.0±18.1 vs. 116.3±15.0 mmHg, p=0.759) and cPP (40.6±9.1 vs. 39.4±8.6 mmHg, p=0.422). Similarly, there was a decrease of cSBP and cPP in patients with empagliflozin treatment under ambulatory conditions, but not in the placebo group. In the whole group, we observed a significant correlation between change in skin sodium content and change in vascular parameters such as cSBP (r=0.364, p=0.004) and cPP (r=0.250, p=0.054) after 1 month of treatment with empagliflozin or placebo.

Conclusion(s)

Significant changes in skin sodium content induced by empagliflozin and a significant correlation between changes in skin sodium content and vascular function suggest that a reduction of tissue sodium content may be one of the mechanisms underlying the beneficial effects of SGLT2 inhibitors in heart failure.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Boehringer Ingelheim International GmbH.

1416Combined therapy of empagliflozin and linagliptin is superior to metformin and insulin glargine in improving blood pressure and vascular function in type 2 diabetes

Background and purpose

The optimal choice of antidiabetic medication in patients that need combined therapy is under debate. The aim of this study was to analyze whether beyond glucose control the combination of empagliflozin (E) and linagliptin (L) improves blood pressure (BP) and vascular function in patients with type 2 diabetes (T2DM) as opposed to the combination of metformin (M) and insulin glargine (I).

Methods

This was a prospective, randomized, controlled, single center study including 101 patients with T2DM, who were randomized 1:1 to E 10–25mg combined with L 5mg once daily or M 850 or 1000mg twice daily combined with I once daily. All patients underwent BP measurement and vascular function analysis by validated systems at baseline and after 12 weeks of treatment.

Results

In comparison to baseline, office, 24-hour ambulatory BP as well as central blood and pulse pressure (PP) values decreased significantly after 12 weeks of treatment with E+L, whereas there was no change in the M+I group (see table). Twenty-four-hour peripheral systolic (mean difference: −5.2±1.5mmHg, p=0.004) and diastolic BP (−1.9±1.0mmHg, p=0.036), central clinical systolic BP (−5.56±1.9mmHg, p=0.009), forward pressure pulse height (−2.0±0.9mmHg, p=0.028), 24-h central systolic BP (−3.6±1.4mmHg, p=0.045) and 24-h pulse wave velocity (−0.14±0.05m/s, p=0.043) were reduced to a greater extent in the E+L than in the M+I group.

Empagliflozin+Linagliptin Metformin+Insulin Baseline 12 weeks p value Baseline 12 weeks p value Peripheral ambulatory BP values   24-h SBP [mmHg] 131.0±10.9 127.0±8.8 <0.001 131.0±9.7 131.0±8.6 0.438   24-h DBP [mmHg] 81.5±7.1 79.7±7.0 0.013 81.0±7.1 81.0±7.5 0.976 Clinical (laboratory) central vascular parameters   Central SBP [mmHg] 123.0±9.6 117.0±10.4 <0.001 121.0±9.9 121.0±8.3 0.944   Central PP [mmHg] 44.4±8.0 41.4±6.6 0.004 43.5±8.6 42.8±7.5 0.471   Forward pressure pulse height [mmHg] 33.0±5.7 30.2±4.6 <0.001 32.5±5.6 31.8±4.5 0.216   Central office PWV [m/s] 8.2±1.6 8.0±1.5 0.039 8.4±1.3 8.3±1.2 0.400 24-h ambulatory central vascular parameters   Central 24-h SBP [mmHg] 120.5±9.3 117.3±7.9 0.007 121.0±9.1 121.0±8.0 0.608   Central 24-h DBP [mmHg] 83.2±7.3 81.1±6.9 0.016 82.4±7.1 82.4±7.7 0.928   Central 24-h PWV [m/s] 8.9±1.3 8.8±1.3 0.010 9.0±1.4 9.0±1.3 0.349 SBP, systolic blood pressure; DBP, diastolic blood pressure; PP, pulse pressure; PWV, pulse wave velocity.

Conclusion

The combination of E+L significantly improves BP and vascular function in contrast to the combination of M+I.

Acknowledgement/Funding

This IIS was supported by a research grant from Boehringer Ingelheim International GmBH

[Lipid profile and cardiovascular risk of participants in the lipid measurement program in the industrial park in Höchst]

BACKGROUND

Cardiovascular (CV) diseases are still the most frequent cause of death in industrial nations. Employer-initiated screening of the CV risk could make an early contribution to optimization of the prevention strategies.

METHODS

In a cross-sectional study the CV risk profile (e.g., dyslipidemia, hypertension, smoking, diabetes mellitus and familial disposition) of 1436 employees at the industrial park in Frankfurt Höchst was analyzed. The total risk was estimated using the PROCAM score.

RESULTS

A hypercholesterolemia (low-density lipoprotein, LDL >130 mg/dl) was detected in 36% of the participants. Of the high-risk participants (myocardial infarct, apoplexy and/or diabetes) 23.7% (n = 9/38) were in the target range for LDL as defined by the European Society of Cardiology (ESC) of below 70 mg/dl, 18.4% (n = 7) had levels between 70 and 100 mg/dl and 57.9% (n = 22) had levels of more than 100 mg/dl. In addition, more than half of the subjects (53.2%) had increased blood pressure values (defined as systolic blood pressure ≥140 mm Hg and/or diastolic blood pressure ≥90 mm Hg). The prevalence of diabetes (blood sugar >126 mg/dl) was very low (1.3%) as was the frequency of manifest CV diseases (1.4% myocardial infarct or apoplexy, 2.9% stabile angina pectoris or peripheral arterial occlusive disease, PAOD).

CONCLUSION

The data confirm that the risk factors high blood pressure and dyslipidemia are widespread and the achievement of target values is insufficient, particularly with a high risk of CV. Behavioral therapeutic and/or pharmaceutical measures should be instigated in order to better exploit the high preventive potential for carriers of these risk factors.

Sotagliflozin: a dual sodium-glucose co-transporter-1 and -2 inhibitor for the management of Type 1 and Type 2 diabetes mellitus

AIMS

To evaluate the evidence for the novel dual sodium-glucose co-transporter-1 (SGLT1) and -2 (SGLT2) inhibitor, sotagliflozin, which may enhance the efficacy of SGLT2 inhibitors by additionally reducing intestinal glucose absorption.

METHODS

The search terms 'sotagliflozin', 'LX4211', 'SGLT' and 'diabetes' were entered into PubMed. Evidence for the pharmacokinetics, pharmacodynamics, safety and efficacy of sotagliflozin in Type 1 and 2 diabetes was extracted from the retrieved literature, critically evaluated, and contextualized in relation to data on existing SGLT2 inhibitors.

RESULTS

There is convincing evidence from a range of phase II and III clinical trials that sotagliflozin significantly improves glycaemic control in both Type 1 and Type 2 diabetes. Additional benefits, such as smaller postprandial plasma glucose excursions, lower insulin requirements, appetite suppression and weight loss have been documented. While this is encouraging, several safety concerns remain; a dose-dependent increase in the rate of diabetic ketoacidosis, diarrhoea and genital mycotic infection is apparent, although statistical exploration of the data regarding such events is currently lacking. Speculatively, use of a 200-mg rather than a 400-mg dose may help to limit unwanted effects.

CONCLUSIONS

The current evidence for sotagliflozin in diabetes appears promising. Further studies sufficiently powered to assess present and emerging safety concerns, as well as to identify individuals for whom sotagliflozin may be of particular benefit/harm would now be informative for regulatory decision-making. Direct comparisons with existing SGLT2 inhibitors are also needed to determine relative safety/efficacy profiles for the different indications.

[Bridging anticoagulation in patients receiving vitamin K antagonists : Current status]

Approximately 30% of patients receiving oral anticoagulation using vitamin K antagonists (VKA) require surgery within 2 years. In this context, a clinical decision on the need and the mode of a peri-interventional bridging with heparin is needed. While a few years ago, bridging was almost considered a standard of care, recent study results triggered a discussion on which patients will need bridging at all. Revisiting the currently available recommendations and study results the conclusion can be drawn that the indications for bridging with heparin must nowadays be taken more narrowly and considering the individual patient risk of bleeding and thromboembolism. Bridging with heparin is only needed in patients with a very high risk of thromboembolism. This overview aims to give guidance for a risk-adapted peri-interventional approach to management of patients with a need for long-term anticoagulation using VKA.

Short-term external counterpulsation augments cerebral blood flow and tissue oxygenation in chronic cerebrovascular occlusive disease

Background and purpose

External counterpulsation improves cerebral perfusion velocity in acute stroke and may stimulate collateral artery growth. However, whether (non‐acute) at‐risk patients with high‐grade carotid artery disease may benefit from counterpulsation needs to be validated.

Methods

Twenty‐eight patients (71 ± 6.5 years, five women) with asymptomatic unilateral chronic severe internal carotid artery stenosis (>70%) or occlusion were randomized to receive 20 min active counterpulsation followed by sham treatment or vice versa. Cerebral blood flow velocity (CBFV) (measured bilaterally by transcranial middle cerebral artery Doppler), tissue oxygenation index (TOI) (measured over the bilateral prefrontal cortex by near‐infrared spectroscopy) and cerebral hemodynamic parameters, such as relative pulse slope index (RPSI), were monitored.

Results

Ipsilateral mean CBFV (ΔV_mean +3.5 ± 1.2 cm/s) and tissue oxygenation (ΔTOI +2.86 ± 0.8) increased significantly during active counterpulsation compared to baseline, whilst the sham had little effect (ΔV_mean +1.13 ± 1.1 cm/s; ΔTOI +1.25 ± 0.65). On contralateral sides, neither counterpulsation nor sham control had any effect on either parameter. During counterpulsation, early dynamic changes in ΔRPSI of the ipsilateral CBFV signal predicted improved tissue oxygenation during counterpulsation (odds ratio 1.179, 95% confidence interval 1.01–1.51), whilst baseline cerebrovascular reactivity to hypercapnia failed to show an association.

Conclusions

In patients with high‐grade carotid disease, ipsilateral cerebral oxygenation and blood flow velocity are increased by counterpulsation. This is a necessary condition for the stimulation of regenerative collateral artery growth and thus a therapeutic concept for the prevention of cerebral ischaemia. This study provides a rationale for further clinical investigations on the long‐term effects of counterpulsation on cerebral hemodynamics and collateral growth.

Combined baseline and one-month changes in big endothelin-1 and brain natriuretic peptide plasma concentrations predict clinical outcomes in patients with left ventricular dysfunction after acute myocardial infarction: Insights from the Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study (EPHESUS) study

OBJECTIVE

Increased levels of neuro-hormonal biomarkers predict poor prognosis in patients with acute myocardial infarction (AMI) complicated by left ventricular systolic dysfunction (LVSD). The predictive value of repeated (one-month interval) brain natriuretic peptides (BNP) and big-endothelin 1 (BigET-1) measurements were investigated in patients with LVSD after AMI.

METHODS

In a sub-study of the Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study (EPHESUS trial), BNP and BigET-1 were measured at baseline and at 1month in 476 patients.

RESULTS

When included in the same Cox regression model, baseline BNP (p=0.0003) and BigET-1 (p=0.026) as well as the relative changes (after 1month) from baseline in BNP (p=0.049) and BigET-1 (p=0.045) were predictive of the composite of cardiovascular death or hospitalization for worsening heart failure. Adding baseline and changes in BigET-1 to baseline and changes in BNP led to a significant increase in prognostic reclassification as assessed by integrated discrimination improvement index (5.0%, p=0.01 for the primary endpoint).

CONCLUSIONS

Both increased baseline and changes after one month in BigET-1 concentrations were shown to be associated with adverse clinical outcomes, independently from BNP baseline levels and one month changes, in patients after recent AMI complicated with LVSD. This novel result may be of clinical interest since such combined biomarker assessment could improve risk stratification and open new avenues for biomarker-guided targeted therapies.

KEY MESSAGES

In the present study, we report for the first time in a population of patients with reduced LVEF after AMI and signs or symptoms of congestive HF, that increased baseline values of BNP and BigET-1 as well as a further rise of these markers over the first month after AMI, were independently predictive of future cardiovascular events. This approach may therefore be of clinical interest with the potential of improving risk stratification after AMI with reduced LVEF while further opening new avenues for biomarker-guided targeted therapies.

[Acute pulmonary embolism: still a diagnostic and therapeutic challenge?]

BACKGROUND

Acute pulmonary embolism (PE) is a cardiovascular emergency with high mortality in which a rapid diagnosis and the early initiation of therapy is vital. In the present study patients with acute PE hospitalized at the Clinic Lippe in Detmold were characterized and their prognosis examined.

METHODS

In our department at the hospital Detmold, all patients with acute PE admitted in 2012 and 2013 were documented with respect to the severity of PE, predisposing risk factors and diagnostic and therapeutic steps.

RESULTS

A total of 170 patients with acute PE were documented of which 80 patients (47 %) had low, 70 patients an intermediate (41 %) and 20 a high risk (12 %). The main diagnostic tool was thoracic computed tomography (82 %). All patients initially received unfractionated or low-molecular weight heparin; systemic intravenous fibrinolysis was carried out in 3 % of patients (intermediate risk n = 1, high risk n = 4). Nineteen percent (n = 13) of the patients at intermediate and 30 % (n = 6) of patients at high risk received local intrapulmonary fibrinolysis. Overall, the mortality rate in hospital was 10 % (low risk 2.5 %; intermediate risk 7 %; high risk 58 %). All 5 patients who received systemic emergency lysis died. One (5.3 %) of the 19 patients at intermediate risk, undergoing local intrapulmonary fibrinolysis, died.

CONCLUSION

In acute PE a rapid diagnosis and the initiation of an adequate therapy remains a big challenge. Further studies are required to evaluate if aggressive treatment options might reduce mortality especially among patients at intermediate or high risk.

[Treatment of coronary three-vessel disease in patients above 75 years]

BACKGROUND

Chronic ischemic heart disease take the first place in cause of death in Germany. The proportion of patients aged 75 years or older amounts more than 80 %. Due to their growing part of population the medical care of older patients becomes increasingly important. In this investigation patients aged ≥ 75 years with coronary three-vessel disease were characterized and various treatment strategies were compared.

PATIENTS AND METHODS

This analysis was retrospective. The data of patients aged 75 years or older with three-vessel disease diagnosed by coronary angiography at the Klinikum Lippe Detmold between 2005 and 2007 were collected. Depending on the received therapy they were parted in three groups: optimal drug therapy (OMT), interventional - (PCI) and surgical revascularization (CABG). Patient characteristics as well as survival- and MACCE-rates during follow up were ascertained. Subgroup analyzes were performed for acute coronary syndrom (ACS) and stable coronary artery disease( CAD).

RESULTS

The data of 434 patients with an average age of 79 years were documented. 139 (32.0 %) were assigned to the OMT- 189 (43.6 %) to the PCI- and 106 (24.4 %) to the CABG-group. Overall there was no significant difference between the three groups regarding mortality. In the subgroup of patients wit ACS (n = 180) mortality significantly increased in the OMT-group compared to the two invasive therapies (PCI (p = 0.029), CABG (p = 0.045)). The subgroup of patients with stable CAD showed no significant differences in mortality between the three types of therapy.

CONCLUSIONS

Older patients benefit from an interventional or surgical revascularization in the context of ACS. In contrast, in elderly with stable CAD optimal medical therapy provides a reasonable alternative to invasive therapy without increase in mortality.

Impact of body weight on antidiabetic treatment and predictors of weight control under real-world conditions: a 2-year follow-up of DiaRegis cohort

AIMS

Treatment strategies for obese patients with type 2 diabetes mellitus aim to increase physical activity, reduce body weight, and improve glucose control using weight-beneficial antidiabetic drugs. The objective of this study was to determine whether these strategies are implemented, and to identify factors predictive of glucose control and body weight management in a large, real-world patient population.

METHODS

The prospective DiaRegis cohort study included 3807 patients with type 2 diabetes in whom the treating physician decided to intensify and optimize treatment because of insufficient glucose control.

RESULTS

Antidiabetic treatment of overweight and obese patients was compared with that of normal-weight patients over a 2-years follow-up period, and multivariate analyses were performed to identify predictors of body weight loss. Among the 3807 participants, 92.5 % were overweight or obese. Normal-weight participants were more often treated with sulfonylureas or insulin, and overweight and obese patients with metformin or glucagon-like peptide (GLP)-1 analogues. Predictors of weight loss were body mass index (BMI) ≥30 kg/m(2) and any reported physical activity.

CONCLUSIONS

DiaRegis study shows that under real-world conditions, antidiabetic drug therapy is performed dependent on body weight. This strategy results in adequate glucose control and moderate weight reductions in overweight and obese patients. Weight loss is affected by treatment with weight-beneficial drugs, but also by any reported physical activity. However, only a small subgroup of patients perform physical activity. Initiation and maintenance of a physically active lifestyle remains a significant challenge for physicians, and patients with type 2 diabetes.

The impact of age on the benefits and risks of aliskiren treatment: analyses of the 3A registry

We aimed to analyze benefits and risks of aliskiren treatment in older adults (⩾ 65 years) in clinical practice. Patients (n = 14,986) were assigned to either aliskiren (ALIS), an angiotensin-converting-enzyme inhibitor or angiotensin receptor blocker (ACEi/ARB), or an agent not blocking the renin-angiotensin system (non-RAS). Older adults (n = 7396) had a longer history of hypertension (8.7 vs 4.7 years; P < 0.0001), lower mean diastolic blood pressure (DBP; 87.7 ± 11.0 vs 92.1 ± 11.0 mm Hg) and more renal (12.0 vs 5.6%; P < 0.0001) or cardiovascular disease (44.0 vs 18.9%; P < 0.0001); 4548 received aliskiren (68.8%), 1215 ACEi/ARBs (18.4%) and 850 non-RAS treatments (12.9%). Office BP at 1 year was reduced by 18.4 ± 21.5/7.2 ± 12.0 mm Hg. BP reductions were greater (19.5 ± 21.7/7.6 ± 12.1 mm Hg) in the aliskiren group than in the ACEi/ARB (15.6 ± 20.9/6.4 ± 11.9) and non-RAS groups (16.1 ± 20.7/6.5 ± 11.7 mm Hg), respectively (P<0.0001 for systolic BP (SBP) and <0.01 for DBP). After multivariable adjustment, differences in SBP reductions were clinically irrelevant and no differences were noted for DBP. Adverse effects were higher in older adults with no differences between treatment groups. In conclusion, the present analysis of a large, unselected cohort of patients in clinical practice from the 3A study, offers real-life evidence of the effectiveness and safety of aliskiren for the treatment of hypertension in older adults.

Composite efficacy parameters and predictors of hypoglycaemia in basal-plus insulin therapy--a combined analysis of 713 type 2 diabetic patients

AIMS

We aimed to identify predictors of hypoglycaemia in patients with poorly controlled type 2 diabetes treated with a single daily bolus of insulin glulisine on top of insulin glargine and oral antidiabetic drugs (basal-plus regimen).

METHODS

We retrospectively analysed four large basal-plus trials including 713 patients (47% female) with type 2 diabetes, mean age of 59.9 ± 9.5 years and diabetes duration of 11 ± 7.0 years. Predictors for symptomatic, severe and nocturnal hypoglycaemia were identified by multivariate logistic regression analyses, calculation of odds ratios (ORs) and Wald 95% confidence intervals (CIs).

RESULTS

Mean numbers of hypoglycaemic events per year were 4.64 ± 11.4 (symptomatic < 60 mg/dl), 0.59 ± 2.28 (nocturnal) and 0.03 ± 0.22 (severe). A total of 44.5% of patients reached the composite endpoint of glycated haemoglobin (HbA1c) <7.0% plus no severe hypoglycaemia, and 26.7% reached the composite of HbA1c <7.0% plus no symptomatic hypoglycaemia. Predictors of nocturnal and symptomatic hypoglycaemia were female gender (OR 1.82; 95% CI 1.07-3.11 and OR 1.89; 95% CI 1.31-2.78), diabetes duration >10 versus <5 years (OR 2.61; 95% CI 1.03-6.59 and OR 2.01; 95% CI 1.15-3.51) and higher basal insulin dose (per unit of increase) (OR 1.01; 95% CI 1.00-1.03 and OR 1.01; 95% CI 1.00-1.02). Conversely, a higher body mass index (BMI) (27-30 vs. <27 kg/m(2) and >30 vs. <27 kg/m(2) ) conferred a reduced risk of symptomatic hypoglycaemia with an OR of 0.53 (95% CI 0.31-0.90) and an OR of 0.61 (95% CI 0.39-0.97).

CONCLUSIONS

Female gender, a long diabetes duration and higher basal insulin dose were predictors of hypoglycaemia, while protection was provided by BMI > 30. These results may help to successfully establish basal-plus insulin regimen in individual patients on their transition from basal-only to basal-bolus treatment.

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.