Saxagliptin/dapagliflozin is non-inferior to insulin glargine in terms of β-cell function in subjects with latent autoimmune diabetes in adults: A 12-month, randomized, comparator-controlled pilot study

AIM

To compare the efficacy and safety of saxagliptin/dapagliflozin and insulin glargine in people with latent autoimmune diabetes in adults (LADA).

METHODS

In this phase 2b multicentre, open-label, comparator-controlled, parallel-group, non-inferiority study, we randomly assigned 33 people with LADA who had a fasting C-peptide concentration ≥0.2 nmol/L (0.6 ng/mL) to receive 1-year daily treatment with either the combination of saxagliptin (5 mg) plus dapagliflozin (10 mg) or insulin glargine (starting dose: 10 IU), both on top of metformin. The primary outcome was the 2-h mixed meal-stimulated C-peptide area under the curve (AUC), measured 12 months after randomization. Secondary outcomes were glycated haemoglobin (HbA1c) levels, change in body mass index (BMI), and hypoglycaemic events.

RESULTS

In the modified intention-to-treat analysis, the primary outcome was similar in participants assigned to saxagliptin/dapagliflozin or to insulin glargine (median C-peptide AUC: 152.0 ng*min/mL [95% confidence interval {CI} 68.2; 357.4] vs. 122.2 ng*min/mL [95% CI 84.3; 255.8]; p for noninferiority = 0.0087). Participants randomized to saxagliptin/dapagliflozin lost more weight than those randomized to insulin glargine (median BMI change at the end of the study: -0.4 kg/m2 [95% CI -1.6; -0.3] vs. +0.4 kg/m2 [95% CI -0.3; +1.1]; p = 0.0076). No differences in HbA1c or in the number of participants experiencing hypoglycaemic events were found.

CONCLUSIONS

Saxagliptin/dapagliflozin was non-inferior to glargine in terms of β-cell function in this 12-month, small, phase 2b study, enrolling people with LADA with still viable endogenous insulin production. Weight loss was greater with saxagliptin/dapagliflozin, with no differences in glycaemic control or hypoglycaemic risk.

The potential for improved outcomes in the prevention and therapy of diabetic kidney disease through 'stacking' of drugs from different classes

Aggressive therapy of diabetic kidney disease (DKD) can not only slow the progression of DKD to renal failure but, if utilized at an early enough stage of DKD, can also stabilize and/or reverse the decline in renal function. The currently recognized standard of therapy for DKD is blockade of the renin-angiotensin system with angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs). However, unless utilized at a very early stage, monotherapy with these drugs in DKD will only prevent or slow the progression of DKD and will neither stabilize nor reverse the progression of DKD to renal decompensation. Recently, the addition of a sodium-glucose cotransporter-2 inhibitor and/or a mineralocorticoid receptor blocker to ACE inhibitors or ARBs has been clearly shown to further decelerate the decline in renal function. The use of glucagon-like peptide-1 (GLP-1) agonists shown promise in decelerating the progression of DKD. Other drugs that may aid in the deceleration the progression of DKD are dipeptidyl peptidase-4 inhibitors, pentoxifylline, statins, and vasodilating beta blockers. Therefore, aggressive therapy with combinations of these drugs (stacking) should improve the preservation of renal function in DKD.

Comparative evaluation of incretin-based antidiabetic medications and alternative therapies to be added to metformin in the case of monotherapy failure

Aims/Introduction:  To compare clinical consequences of using inretin-based medications versus conventional antidiabetic agents as add-on to metformin in case of monotherapy failure in patients with type 2 diabetes.

MATERIALS AND METHODS

  The medical literature including recent abstracts from international diabetes conferences was searched for reports from clinical trials with incretin mimetics (GLP-1 receptor agonists), inhibitors of dipeptidyl peptidase-4 (DPP-4, incretin enhancers) and conventional antidiabtic drugs coadministered with metformin after monotherapy failure. A scoring system is suggested to compare the clinical utility of using incretin-based versus conventional antidiabetic agents in this situation.

RESULTS

  Incretin mimetics and DPP-4 inhibitors on top of metformin treatment help achieve glycaemic control comparable to other efficient antidiabetic drugs, both if separate or head-to-head trials were considered. Incretin-based antidiabetic drugs did not cause hypoglycaemia (different from sulfonylureas, meglitinides and insulin) and weight gain (different from sulfonylureas, meglitinides, thiazolidinediones, and insulin). DPP-4 inhibitors were weight neutral, incretin mimetics lead to weight loss. The clinical profile of incretin-based medications received the highest scores, followed by α-glucosidase inhibitors, with far lower scores assigned to insulin, glitazones, and sulfonyureas (in this order).

CONCLUSIONS

  Based on the results from clinical trials, incretin-based medications have been shown to be efficacious antidiabetic drugs with a favourable adverse event and tolerability profile. This leads to high scores using a novel system paying attention to multiple facets contributing to the selection of antidiabetic drugs for general recommendation and individual treatment choices.