Should We Continue Insulin Secretagogues When Starting Insulin for Type 2 Diabetes?

Anne L. Peters, MD, CDE


July 08, 2010

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Hi. I'm Dr. Anne Peters, the Director of the Clinical Diabetes Programs at the University of Southern California. Today I'm going to talk about using oral agents in conjunction with insulin when we start patients on insulin therapy.

I'm at the American Diabetes Association annual meeting in Orlando, Florida. And one of the abstracts that I think is interesting is from a 24-week trial that studied patients with type 2 diabetes in whom oral agents failed so they were then started on insulin.[1] This trial, which is funded by Sanofi Aventis, compares glargine with detemir and includes 964 patients from sites around the world.

In this study, the investigators were allowed to continue their patients on metformin or on metformin and sulfonylurea together. The investigators decided whether to stop the sulfonylurea agent. About half of the patients were receiving the long-acting insulin plus metformin alone, and in about the other half, an insulin secretagogue -- generally a sulfonylurea agent -- was continued. They compared the 2 groups.

In both groups, hemoglobin A1C fell to 7.2% -- a decrease greater than 1% regardless of whether they were receiving metformin alone or metformin plus a secretagogue. But there were interesting differences in the 2 groups. Those who remained on an insulin secretagogue had a much higher rate of reported hypoglycemia: 40% compared with 24% in those who were receiving metformin alone. Additionally, maintaining the insulin secretagogue was associated with more weight gain: 1.44 kg vs 0.4 kg in those receiving metformin alone.

The dose of insulin that was achieved was lower in the patients who were on the insulin secretagogue, and that makes some sense. They were only titrated up to 0.6 units of insulin per kg per day vs 0.8 units per kg per day in those on insulin and metformin.

I found this trial useful because, frankly, I often don't know whether to continue the oral agents when I start patients on insulin. My gut feeling has been to continue the metformin because it doesn't cause hypoglycemia or weight gain, and I've been torn about whether to stop the secretagogue. But looking at these results, it makes some sense to stop the secretagogue; to continue the metformin; and then to up-titrate the basal insulin to get the fasting glucose level to the desired range, and for most patients that range is going to be somewhere between 80-120.

I also thought this trial was interesting because it provides practical data that I can use to help my practice, and I think it might help us all achieve better patient outcomes when transitioning them to insulin.

This has been Dr. Anne Peters for Medscape. Thank you.


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