Unsure on the Best T2D Drug Choice? Let Patients Decide

Mitchel L. Zoler, PhD

September 26, 2022

STOCKHOLM, Sweden — When a clinician is unsure which of several equally viable drug options is best for a specific patient with type 2 diabetes, a rational approach is to run a serial trial with each one and then let each patient decide which agent works best for them.

That concept underwent successful testing in a recent trial with 457 patients with type 2 diabetes and already on treatment with metformin or metformin plus a sulfonylurea but needed further glycemic control. After cycling through 4-month trials (when tolerated) of canagliflozin (Invokana), pioglitazone (Actos), and sitagliptin (Januvia), 24% identified pioglitazone as the one that made them feel best, 33% favored sitagliptin, 37% said canagliflozin was tops, and 6% had no preference, Beverley Shields, PhD, reported at the annual meeting of the European Association for the Study of Diabetes.

After making these selections based on just their qualitative self-appraisals, researchers told patients about their hemoglobin A1c status on each of the three agents. It barely budged their choices, which became 25% calling pioglitazone best, 35% naming sitagliptin their preference, 38% opting for canagliflozin, with 2% having no preference.

Further analysis showed that the drug patients preferred was also the one that produced their lowest A1c level when compared with their 8 months on each of the two other agents tested, showing a link between lower A1c levels and improved well-being. The same relationship existed for the drug that caused the fewest adverse events for each patient.

Patients Prefer Feeling Better

"Patients tended to prefer the drug that they 'felt better' on, with the lowest A1c level and the lowest number of side effects," explained Shields, a medical statistician at the University of Exeter (England). Changes in weight appeared less important to patients for establishing a preference.

"This is for when there is equipoise" among drug options, Andrew Hattersley, BMBCh, DM, the study's principal investigator, said in an interview. "When you are unsure what to prescribe and there is no clear indication for one drug over another, try 4 months of one and 4 months of the other, then let the patient decide.

"Patients had overwhelming positivity about being able to choose their drug," added Hattersley, who is also professor of molecular medicine at the University of Exeter.

"This has implications across medicine," he added. "Whenever you're not sure how to balance adverse effects and positive effects the best person to decide is the one who experiences the effects."

"I'm a bit worried by this approach, but it is something new" and worth considering, commented Drazenka P. Barlovic, MD, an endocrinologist at the University Medical Center in Ljubljana, Slovenia, who chaired the session where Shields gave her report. "We should also have the courage to challenge metformin, as there is no longer an obligation to make it the first drug," she said in an interview.

The study ran as a secondary analysis of the TriMaster study, which had the primary objective of identifying patient characteristics that could predict which of the three drug options tested worked best for certain patient subgroups. That analysis, presented at the 2021 EASD annual meeting, found that factors such as body mass index and kidney function significantly linked with the clinical responses patients had to each of the three tested agents.

The new analysis focused on 457 of the TriMaster participants who had provided preference information after they had tried all three agents. By design, none of the participants enrolled in the study had a contraindication for any of the tested drugs.

Patients Quickly Identify Adverse Effects

"We picked 4 months because it was not too long, but long enough to see adverse effects, and to measure on-treatment A1c. Patients quickly identify their adverse events," Shields said in an interview.

"This could come into practice now; there is no cost involved. Do it when you're not certain which drug to prescribe," Hattersley suggested. "We can't know which drug a patient might prefer." He also stressed telling patients to return quicker than 4 months if they can't tolerate a new drug.

The findings have already changed Hattersley's practice, and he believes it will catch on as he introduces it to local primary care physicians.

The study received no commercial funding. Shields, Hattersley, and Barlovic had no disclosures.

This article originally appeared on MDedge.com, part of the Medscape Professional Network.

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