Early second-line therapy response predicts sustained HbA1c reductions in type 2 diabetes
medwireNews: Early achievement of a glycated hemoglobin (HbA1c) level below 7% (58 mmol/mol) is a key factor in maintaining long-term glucose control in people with type 2 diabetes initiating second-line glucose-lowering therapy, DISCOVER study data show.
“Our results suggest that patients with an elevated HbA1c level after 6 months following initiation of second-line glucose-lowering therapy should be considered as being at high risk of persistent poor glycaemic control, and therefore should have their treatment intensified in a timely manner to minimize therapeutic inertia,” write Fabrice Bonnet (Rennes University Hospital, France) and co-authors in Diabetes, Obesity & Metabolism.
They found that, at 6 months after initiation of second-line glucose-lowering therapy, HbA1c levels had fallen below 7.0% in 43.7% of 5342 prospective, international DISCOVER study participants with baseline HbA1c levels at or above 7.0% but below 9.0% (57 mmol/mol; mean 7.8%, 62 mmol/mol). At 3 years, this proportion had increased slightly to 45.8%.
Of the 2233 participants with baseline HbA1c at or above 9.0% (mean 10.4%, 90 mmol/mol), 24.2% had a level below 7.0% after 6 months of second-line therapy, increasing to 29.3% after 3 years.
The proportions with HbA1c levels at or above 9.0% at 3 years were 6.1% in the former group and 18.6% in the latter.
In both groups, the most common first-line treatment was metformin monotherapy, with dual therapy the most common second-line choice. Second-line insulin, alone or in combination with other agents, was prescribed in 3.3% of patients with a baseline HbA1c level of 7.0% to less than 9.0%, and in 14.5% of those with a baseline HbA1c level above 9.0%.
Multivariable analysis showed that people with an HbA1c below 7.0% at 6 months were at least twice as likely as those with a higher level to have an HbA1c below 7.0% at 3 years, with odds ratios of 2.01 in group with baseline HbA1c of 7.0% to less than 9.0% and 2.68 in the group with baseline levels at or above 9.0%.
In addition, a diabetes duration of 10 or more years versus less than 5 years was associated with 19% and 40% lower likelihoods, respectively, of having HbA1c below 7.0% at 3 years.
In general, the choice of second-line therapy was not significantly associated with HbA1c at 3 years, but people who had a baseline HbA1c level of 9.0% or higher were 1.79 times more likely to achieve the HbA1c target with metformin plus a dipeptidyl peptidase-4 inhibitor than with insulin.
Bonnet et al say that their findings “highlight great disparities in the response to glucose-lowering therapies and substantial difficulties in achieving long-term glycaemic control in some of these patients in real-world practice, potentially leaving them at increased risk of microvascular complications.”
They conclude that the “results emphasize the importance of early glycaemic control with timely treatment intensification, as recommended by clinical guidelines.”
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