Adding second diabetes medication better than switching in face of poor response
medwireNews: Adding an additional glucose-lowering medication is better than switching to a different one in people with type 2 diabetes, even if the original seemed to have little or no effect, shows an analysis from the MASTERMIND consortium.
The findings presented at the Diabetes UK Professional Conference in Liverpool, by Andrew McGovern (University of Exeter Medical School, UK), build on the consortium’s previous finding that individual glycated hemoglobin (HbA1c) levels are extremely variable – “noisy,” as McGovern put it – meaning that treatment effects may be obscured by the natural variation in HbA1c levels.
This latest analysis included 12,168 people with type 2 diabetes, identified in the UK Clinical Practice Research Datalink, who started a new antidiabetes medication (excluding insulin) but had no or only a limited response, defined as a reduction of less than 5.5 mmol/mol (0.5%) during 6 months of use.
McGovern noted that this situation is relatively common, affecting 21% of patients who started on a new medication. Over the following year, most people (n=8939) continued on the same medication, whereas 1119 switched to a different medication and 2110 added a second medication.
According to the team’s hypothesis, the apparent poor treatment response in these patients was actually due to the medication’s effects being obscured by the natural variation in HbA1c levels.
“If that is true, then stopping that medication and switching it to something else will not improve their HbA1c,” said McGovern. “That medication did work, but it was lost in the noise.
“The only way you can improve their HbA1c is add on top. If we’re wrong, then switching is the better option.”
The study findings support the team’s hypothesis. HbA1c levels decreased by just 5 mmol/mol in people who continued with their existing medication, and switching was only slightly better, giving a fall of an additional 1.70 mmol/mol, which was not significant in a propensity-matched analysis.
But adding a second medication resulted in a markedly larger decrease, giving a 7.26 mmol/mol difference compared with in people who continued with the same medication. This remained significant in a propensity-matched analysis, whereas the small difference between continuing and switching medications disappeared.
“The take-home message is that no change in HbA1c does not mean that person has had no response to that treatment,” said McGovern.
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