Oral regimens could offer simple solution for severe hyperglycaemia

By Eleanor McDermid

Study findings indicate that oral treatments could offer a simpler alternative to upfront insulin for patients who have severe hyperglycaemia at the time of diagnosis with Type 2 diabetes.

Either of two oral regimens - involving a sulphonylurea or combined dipeptidyl peptidase-4 inhibitor plus metformin - were effective, say Ambika Amblee (Cook County Health & Hospitals System, Chicago, Illinois, USA) and co-researchers.

During 12 weeks of treatment, glucose levels among the 50 patients randomly assigned to receive daily saxagliptin 5 mg and metformin 2000 mg fell from an average of 343 to 137 mg/dL, with a marked reduction seen within the first week of treatment, to 250 mg/dL.

The 50 patients assigned to receive glipizide 10 mg/day had a very similar response, with blood glucose levels falling from 341 to 129 mg/dL (243 mg/dL at week 1).

Likewise, glycated haemoglobin levels fell from 10.8% to 6.8% in the saxagliptin/metformin group and from 11.0% to 6.9% in the glipizide group.

Amblee et al say that "the response rate was very high in both groups, which suggests that both discharge regimens are efficacious". Just 6% and 2% of patients in the saxagliptin/metformin and glipizide group, respectively, failed to achieve predetermined blood glucose levels.

The researchers therefore suggest that oral medication could be a reasonable alternative to the currently recommended strategy of immediate insulin therapy, given that "initiating insulin therapy in busy acute care settings can be difficult", as well as distressing for newly diagnosed patients.

However, they note that, while both oral medication regimens effectively reduced blood glucose, "the combination of saxagliptin with metformin seems safer with regard to hypoglycemia."

Just 8% of patients in this group had a hypoglycaemic episode during treatment (four in total) compared with 24% of the sulphonylurea group, who had 27 episodes between them.

In addition, insulin resistance decreased significantly more in the combined treatment group, with Homeostasis Model Assessment for insulin resistance values falling from 5.4 to 3.3, compared with from 6.1 to 5.0 in the sulphonylurea group. The team attributes this to the effects of metformin on insulin resistance.

"This study shows that use of simple oral regimens can simplify the discharge regimens for busy acute care sites", write the researchers in The Journal of Clinical Endocrinology & Metabolism.

"This will eliminate the need for insulin use education along with the complex requirements of multiple insulin injections and intense glucose monitoring for those dealing with a new diagnosis of [Type 2 diabetes mellitus]."

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