medwireNews: People with type 1 diabetes who take glucagon-like peptide (GLP)-1 receptor agonists or sodium-glucose cotransporter (SGLT)2 inhibitors in clinical practice have outcomes that are mostly – but not all – in line with those in controlled trials, say researchers.
The study included 76 people with type 1 diabetes who took a GLP-1 receptor agonist for an average duration of 20.5 months. The most common reason for starting the medication was the need for weight loss (69.4%), followed by improved glycemic control (50.9%), reduced glucose variability (13.0%), and reduced insulin dose (7.4%).
In line with findings from clinical trials, after 12 months of use people taking a GLP-1 receptor agonist had a significant reduction in glycated hemoglobin (HbA1c), from an average of 7.7% to 7.3% (61 to 56 mmol/mol), as well as in bodyweight, from an average of 90.4 to 85.4 kg.
Users of GLP-1 receptor agonists also reduced both their basal and bolus daily insulin use, from an average of 30.7 to 26.0 units and from 37.9 to 27.9 units, respectively.
Khary Edwards (University of Texas Southwestern Medical Center, Dallas, USA) and study co-authors note in The Journal of Clinical Endocrinology & Metabolism that the average 0.4% reduction in HbA1c “might not be viewed by some as clinically relevant,” but say that this finding should be “viewed holistically at a patient level.”
They stress the challenge of improving glycemic control in people with longstanding type 1 diabetes and the additional benefits of weight loss and reduced insulin needs.
SGLT2 inhibitors were used by 39 study participants for an average duration of 24.2 months, mostly with the intent to achieve better glycemic control (73.3%), but also for weight loss (37.8%), reduced insulin requirements (26.7%), and reduced glucose variability (24.4%). Also, about 12% of users initiated SGLT2 inhibitors for their beneficial cardiovascular or renal properties.
In line with clinical trial findings, these real-world users had significant reductions in average HbA1c after 12 months of use, from 7.9% to 7.3% (63 to 56 mmol/mol), and in basal insulin dose, from a daily average of 31.3 to 25.6 units, but not in bolus insulin.
And contrary to the results of controlled trials, although SGLT2 inhibitor users had a weight reduction, this was small and not statistically significant, at an average of 89.2 and 87.5 kg before and after 12 months, respectively.
“While this could be due to our smaller sample size, other larger real-world studies also had conflicting results,” say the researchers, adding that more research is needed to determine whether the benefits of SGLT2 inhibitors found in clinical trials “fully translate to real-world practice.”
Prior to starting an adjunctive medication, the rate of diabetic ketoacidosis (DKA) was 2.6 episodes per 100 patient–years in the SGLT2 inhibitor users versus 6.6 per 100 patient–years in those who went on to initiate a GLP-1 receptor agonist.
The researchers suggest this difference could be caused by doctors avoiding SGLT2 inhibitors in people with an elevated baseline DKA risk. Initiating SGLT2 inhibitors was associated with a rise in the rate of DKA, to 6.6 episodes per 100 patient–years.
The team says this rate is higher than those reported in clinical trials, but adds: “It is not surprising that in the real world DKA would occur more frequently than in a clinical trial, where patient selection is more stringent, there is frequent and intense monitoring, and structured patient education.”
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