medwireNews: Patients with type 2 diabetes last for longer before needing treatment intensification if they are treated with fixed-ratio combination insulin degludec and liraglutide (IDegLira), rather than insulin glargine 100 U/mL, show the DUAL VIII findings.
The median time to treatment intensification was more than 2 years for people randomly assigned to IDegLira, compared with around 1 year for those given glargine. Over 104 weeks of treatment, a respective 37% versus 66% needed intensification, which was defined as having a glycated hemoglobin (HbA1c) level of 7.0% (53 mmol/mol) or higher at two consecutive visits.
The team led by Vanita Aroda (Brigham and Women’s Hospital, Boston, Massachusetts, USA) reported their findings this week at the 79th ADA Scientific Sessions in San Francisco, California, USA.
The results are simultaneously published in The Lancet Diabetes & Endocrinology, in which the researchers attribute the improved durability of IDegLira to the complementary actions of the insulin and the glucagon-like peptide (GLP)-1 receptor agonist, giving the combination treatment the “ability to target both fasting and postprandial hyperglycaemia compared with the use of basal insulin alone.”
DUAL VIII involved 1012 people whose type 2 diabetes had worsened to the point of them requiring an injectable treatment. Almost all were taking metformin, with around two-thirds also taking a sulfonylurea and a third a dipeptidyl peptidase-4 inhibitor, the latter of which was discontinued at randomization.
The trial was open-label and “designed to mirror recommended routine clinical practice and decision making,” according to the researchers. The participants had just three visits during the initial 12-week dose titration period followed by every 3 months to assess treatment response.
Patients taking IDegLira were significantly more likely than those taking glargine to maintain their HbA1c below 7.0% without experiencing weight gain or severe/blood glucose-confirmed hypoglycemia.
The researchers attribute this to “the insulin-sparing and beneficial weight effects of liraglutide,” as well as the lower rate of hypoglycemia reportedly associated with degludec compared with glargine.
In a linked commentary, Srikanth Bellary and colleagues from University Hospitals Birmingham NHS Foundation Trust in the UK, say that the findings “provide important insights into the potential role of fixed ratio combination therapy in the treatment algorithm for type 2 diabetes.”
However, they criticize the lack of a group given a GLP-1 receptor agonist only, saying that “a valuable opportunity to provide a more definitive answer regarding the relative merits of all three of these options has been missed.”
This is particularly relevant given the recent ADA/EASD recommendations for use of GLP-1 receptor agonists as the preferred add-on to metformin in patients with established atherosclerotic disease, they add.
The commentators call for further research, and conclude: “The choice between a fixed ratio combination, GLP-1RA, or basal insulin needs to be individualised and should include issues such as patient preference, cardiovascular disease status, potential for side-effects, and glycaemic control.”
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Lancet Diabetes Endocrinol 2019; doi:10.1016/ S2213-8587(19)30184-6
Lancet Diabetes Endocrinol 2019; doi:10.1016/S2213-8587(19)30198-6
79th ADA Scientific Sessions; San Francisco, California, USA: 7–11 June 2019
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