Editorial board commentary
The SUSTAIN 4 trial assesses the efficacy and safety of semaglutide in insulin-naïve type 2 diabetes patients on oral therapy. It compares this once weekly GLP-1 analogue (in a 0.5mg or 1.0 mg dose) with once-daily glargine.
Semaglutide demonstrates better glucose-lowering efficacy, along with the added benefit of weight loss and lesser hypoglycemia. The results of SUSTAIN 4 must be read in conjunction with those of SUSTAIN 6, which has demonstrated the cardiovascular safety and benefit of this drug. Both these studies support its use as a preferred first line injectable in type 2 diabetes, especially in overweight/obese patients, and in those at high risk of hypoglycemia. The once-weekly dosage schedule allows semaglutide to be used as weekend therapy, and as DOT (directly observed therapy), in persons who are unable to, or do not wish to, self-inject on a daily basis. It also enhances adherence in persons who find it difficult to inject at the same time each day.
The discontinuation rate with semaglutide (14–15%) must also be noted: it can be reduced further by ensuring adequate medication counseling.
As newer drugs, and drug combinations, are developed, we need to choose appropriate therapy in a patient-centered manner. This holds true for injectable therapy as well. The relative efficacy, pleiotropic benefits, safety and tolerability of these drugs, as shown by SUSTAIN 4 and other randomized controlled trials, will help us take the right decision. Armed with these results, we should be able to match the correct drug to the correct patient, and vice versa, so that safe and effective glycemic control can be achieved in all persons with diabetes.