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Second- and Third-Line Pharmacotherapy for Type 2 Diabetes: Update [Internet]. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; 2013 Jul. (CADTH Optimal Use Report, No. 3.1.)

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Second- and Third-Line Pharmacotherapy for Type 2 Diabetes: Update [Internet].

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1BACKGROUND

Type 2 diabetes mellitus is a progressive disease and many patients will eventually require treatment with exogenous insulin to maintain glycemic control. Insulin therapy for patients with type 2 diabetes is typically initiated with a basal insulin. Clinical practice guidelines typically recommend intensification of an insulin regimen for most patients inadequately controlled with basal insulin, such as through the use of a biphasic insulin or a basal-bolus insulin regimen. Two dipeptidyl peptidase-4 (DPP-4) inhibitors, saxagliptin (Onglyza) and sitagliptin (Januvia) were recently given approval by Health Canada for use in combination with basal or biphasic insulin when these insulins do not provide adequate glycemic control. In addition, the GLP-1 analogue exenatide (Byetta) has been approved by Health Canada for use in combination with insulin glargine, and liraglutide (Victoza) has Food and Drug Administration approval for use in combination with insulin. The regulatory status of combination use of incretins and insulin is summarized in Table 1.

Table 1. Regulatory Status of Incretins Combined With Insulin.

Table 1

Regulatory Status of Incretins Combined With Insulin.

There is uncertainty regarding the comparative effectiveness of insulin intensification versus the addition of a DPP-4 inhibitor or a glucagon-like peptide-1 (GLP-1) analogue for patients inadequately controlled with basal/biphasic insulin. Therefore, a supplemental review of the evidence for the combination of incretins and insulins was conducted.

1.1. Objective

The objective of this review was to summarize and critically appraise the evidence regarding the clinical effectiveness and harms of combination use of DPP-4 inhibitors or GLP-1 analogues with insulin. The following research questions were assessed:

  1. What is the clinical efficacy and safety of DPP-4 inhibitors used in combination with insulin for patients with inadequate glycemic control on a basal or biphasic insulin regimen?
  2. What is the clinical efficacy and safety of GLP-1 analogues used in combination with insulin for patients with inadequate glycemic control on a basal or biphasic insulin regimen?
Copyright © CADTH 2013.
Bookshelf ID: NBK169676
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