DPP4i preferred as third line after metformin+sulfonylurea in T2D

  • Wong CKH & al.
  • PLoS Med
  • 1 Dec 2019

  • International Clinical Digest
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Takeaway

  • For patients with type 2 diabetes (T2D) on metformin+sulfonylurea (Met-SU) therapy, adding a dipeptidyl peptidase-4 inhibitor (DPP4i) incurred the lowest risks for all-cause mortality (ACM), cardiovascular disease (CVD) events, and severe hypoglycemia (SH) vs insulin or thiazolidinedione (TZD).

Why this matters

  • 2019 guidelines advise TZD following Met-SU when cost is a major issue in T2D patients without existing CVD.

Study design

  • Retrospective analysis of 17,293 patients with T2D without baseline CVD on Met-SU, intensified with either DPP4i (n=8248), insulin (6395), or TZD (2650) during 2006-2017.
  • Funding: Food and Health Bureau, Hong Kong.

Key results

  • During mean follow-up of 34 months and after weighting: 
    • Adding insulin was tied to the highest ACM: incidence rate, 2.748/100 person-years. 
    • Intensification with TZD was tied to the most SH (4.896/100 person-years) and CVD (2.583/100 person-years).
  • Compared with DPP4i, SH risks (HRs) were: 
    • Insulin: 1.496; 
    • TZDs: 1.249 (both P<.001>
  • Compared with SH risk, ACM risk with insulin increased to 2.648 vs TZD and 2.352 vs DPP4i (both P<.001>
  • Differences were not significant for:
    • ACM in comparisons between TZD and DPP4i, or
    • CVD in comparisons between insulin and DPP4i, TZD and DPP4i, and insulin and TZD.

Limitations

  • No data on lifestyle factors, drug adherence, time-varying factors.
  • Short follow-up.