De-intensification of bolus insulin in type 2 diabetes after GLP-1 RA initiation improves blood sugar and aids weight loss

Type 2 diabetes is a chronic condition characterized by insulin resistance, hyperglucagonaemia, and progressive beta-cell dysfunction. Type 2 diabetes patients are commonly given metformin initially, and if the glycemic targets remain unmet, different combinations of antihyperglycaemic agents can be considered and individualized. In cases where other agents fail to achieve or maintain glycemic targets, Treatment intensification to insulin therapy should be considered.

Even after treatment intensification with basal insulin, 30–64% of type 2 diabetes patients receiving oral antidiabetic drugs (OADs) and insulin do not achieve an HbA1c target of <53 mmol/mol. For these patients, adding bolus insulin, basal-bolus insulin therapy, or a change to premixed insulin or insulin coformulations is often considered the next step for improving glycemic control. In people with diabetes, two fixed-ratio combinations (FRCs) of basal insulin and GLP-1 receptor agonists are available for once-daily use in adults with type 2 diabetes.

Against the above background, Cristina Bianchi, Department of Medicine, University Hospital of Pisa, Pisa, Italy, and colleagues conducted a study to investigate the impact of glucagon-like peptide-1 receptor agonist (GLP-1 RA) addition in type 2 diabetes patients in basal-bolus (BB) insulin regimen, on HbA1c, insulin requirement, weight loss up to 24 months.

For this purpose, the researchers retrospectively collected data on T2D patients on BB who initiated a GLP-1 RA. The recording of body weight, HbA1c, and insulin dose was done at baseline 6, 12, and 24 months following GLP-1 RA therapy initiation. Changes in body weight, HbA1c, and insulin requirement were evaluated over time.

The main findings of the study include:

• 156 participants (63.5% males; age 62 ± 11 years, HbA1c 70 ± 22.0 mmol/mol; 8.6 ± 4.2%) were included.
• HbA1c and body weight compared to baseline was significantly lower at six months after GLP-1RA introduction and remained stable up to 24 months.
• At 24 months, 81% of subjects discontinued prandial insulin, while 38.6% discontinued basal insulin.
• Insulin requirement at baseline (aOR 0.144) was the only significant predictor of prandial insulin discontinuation.

Replacing prandial insulin with GLP-1 RA is a valuable strategy to simplify the BB insulin regimen while improving glycaemic control and promoting weight loss in subjects with T2D.

Reference:

Falcetta P, Nicolì F, Citro F, Ciccarone A, Garofolo M, Del Prato S, Bianchi C. De-intensification of basal-bolus insulin regimen after initiation of a GLP-1 RA improves glycaemic control and promotes weight loss in subjects with type 2 diabetes. Acta Diabetol. 2022 Sep 27. doi: 10.1007/s00592-022-01974-0. Epub ahead of print. PMID: 36166172.