medwireNews: Adding the dipeptidyl peptidase-4 (DPP-4) inhibitor sitagliptin to basal insulin reduces bolus insulin requirements in hospitalized patients with type 2 diabetes, shows a randomised trial.
The trial met its non-inferiority endpoint, with average daily blood glucose concentrations being 9.5 mmol/L in 138 patients taking basal insulin plus sitagliptin, and 9.4 mmol/L in 139 patients on a standard basal–bolus insulin regimen.
The rate of complications was similar in both groups, with acute kidney injury the most common, and neither the proportion of patients with hypoglycemia (<3.9 mmol/L) nor of hypoglycemic blood glucose readings per group differed.
The patients were aged an average of 56.9 years, 60% were men, and their average diabetes duration was 10.3 years. All patients experienced a “prompt and sustained improvement” in their blood glucose levels during their hospital stay, which lasted a median of 4 days. Patients in the sitagliptin group received a single daily 100 mg dose, at any time of day, or a 50 mg dose if they had reduced kidney function.
Guillermo Umpierrez (Emory University, Atlanta, Georgia, USA) and study co-authors write in The Lancet Diabetes & Endocrinology that a basal insulin plus sitagliptin regimen could be a “more convenient alternative to the standard basal–bolus insulin regimen, particularly in hospitals and areas of low staffing and resources.”
However, writing in a linked commentary, Michael Nauck and Juris Meier, both from St Josef-Hospital in Bochum, Germany, are more circumspect.
Patients taking sitagliptin required less insulin, at 24.1 versus 34.0 units per day, which was accounted for by a large reduction in prandial rapid-acting insulin needs, at 0.4 versus 11.7 units, in line with the known actions of DPP-4 inhibitors on postprandial glucose. But this only equated to an average reduction of 0.7 insulin injections per day.
“Whether these results represent a major simplification for either the patients or the medical staff can be debated, especially in view of the equal need for glucose measurements in both groups,” write Nauck and Meier.
The commentators also note that the trial was conducted in highly expert tertiary centers, and suggest that, “in an environment with less experienced staff, the simplified treatment algorithm with glargine and sitagliptin might also lead to a delay in treatment escalation to a basal–bolus regimen.”
They say: “Such a delay could potentially prolong periods of harmful hyperglycaemia.”
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