Short-Term Outcomes for Veterans Receiving Basal Insulin, Metformin, and a Sulfonylurea Who Are Started on a Third Noninsulin Agent Versus Prandial Insulin

AIMS. Despite numerous recent advances in the management of patients with type 2 diabetes, there remains a paucity of data to guide sequential treatment intensification. METHODS. This was a single-center, retrospective cohort study of patients receiving metformin, basal insulin, and a sulfonylurea who were started on a third noninsulin agent or prandial insulin. The primary outcome for this study was change in A1C at 6 months after treatment intensification. Secondary outcomes included change in weight at 6 months, change in A1C at 1 year, percentage of patients achieving an A1C <7.5% at 1 year, documented episodes of hypoglycemia, and time to progression to prandial insulin. RESULTS. A total of 62 patients were identified for inclusion in the study: 28 receiving prandial insulin and 34 treated with a noninsulin agent. There was no significant difference in A1C change between the two treatment arms at either 6 months (–0.53 vs. –0.84%, P = 0.31) or 1 year (–0.67 vs. –0.86%, P = 0.61) after intervention. Patients receiving noninsulin agents gained significantly less weight at 6 months (–2.09 vs. 1.99 kg, P <0.01) and experienced fewer annual episodes of hypoglycemia (1.0 vs. 2.6, P = 0.01). Among patients treated with noninsulin agents, those receiving a glucagon-like peptide 1 receptor agonist were more likely to have an A1C <7.5% at 1 year than patients receiving a dipeptidyl peptidase 4 inhibitor (50 vs. 13%, P = 0.05). CONCLUSION. These results highlight that, in select patients, noninsulin therapies can be added to a backbone of metformin, basal insulin, and a sulfonylurea with similar A1C reductions but improved metabolic parameters relative to intensive insulin therapy.