WHEN AND HOW TO USE A GLP-1 RA WITH LONG-OR ULTRALONG-ACTING BASAL INSULIN IN T2DM

摘要

Compared with the traditional use of prandial insulin to intensify a basal insulin regimen in T2DM, the use of GLP-1 RAs with long-or ultralong-acting basal insulin results in equivalent glycemic control with a lower risk of hypoglycemia or weight gain. This new treatment regimen has a burgeoning evidence base to support its use and is now recommended in current treatment guidelines. The ultralong-acting basal insulin degludec has been tested in combination with GLP-1 RAs and is associated with high efficacy with a low risk of hypoglycemia or weight gain. Recently, two coformulations of basal insulin and a GLP-1 RA were recommended for FDA approval. Combinations of insulin and GLP-1 RAs are notable for their higher likelihood of attaining a composite endpoint of A1C <7% without hypoglycemia and without weight gain, relative to basal, basal-plus, or basal-bolus insulin therapy. Patients who are especially likely to benefit from using insulin in combination with a GLP-1 RA include those unable to attain their glycemic targets on a single injectable agent and those who require insulin therapy but also want to avoid weight gain. However, GLP-1 RAs have important agent-specific contraindications and cautions and are approved for use only in T2DM. In patients with little or no residual beta-cell function, or in those with certain medical histories or comorbidities, prandial insulin may be a more appropriate choice for intensifying a basal insulin regimen.