Positioning Insulin vs GLP-1 Agonists in Type-2 Diabetes Insufficiently Controlled on Oral Agents The case for: Insulin Goes First; Steve Edelman; ADA 2011.

The approach to patients failing on oral therapies in DM2 should be individualized to the patient. There are clear reasons for using basal insulin – it has been tested much more thoroughly, has been around for 90 years and is much cheaper than GLP-1 analogues. There are many drugs in this time that have fallen by the wayside as their safety profile becomes established through years of clinical use. To prove the difference in knowledge base between GLP-s and basal insuln simply google search for GLP-1 analogue and compare the number of hits with a google search for basal insulin therapy.

In Monnier’s analysis it was the fasting blood sugar that was the largest determinant of HbA1c in patients with higher HbA1c. Thus it makes sense to target FBG in selecting add-in therapy when faced with poorly controlled HbA1c.

In the Treat to Target study there was a fall in HbA1c from 8.6% to 7% and this was a significantly greater fall than GLP-1 analogues have been shown to achieve. In this trial the hypo rate was actually lower than is often suggested.

In the AT.LANTUS study there was a significantly greater HBa1c reduction in the patient driven titration group, and although there was a slightly greater hypo rate, it was only in those categories of hypo that did not have significant clinical impact.

The LANMET study showed that insulin naïve patients starting basal insulin had a fall in HbA1c from 9.5% to 7.1% with the patients self-adjusting to titrate. These changes were achieved without the risk of severe hypo.

In the 3 Amigo studies there was a staring HbA1c of only 8.5% and there was only a 0.8% reduction with a weight loss, which could be considered relatively meaningless. In addition in the exenatide studies about 33-43% of patients reported nausea that leads to vomiting consistently in more than 5%. There is also the issue of acute pancreatitis and c-cell thyroid tumours in GLP-1 therapy which resulted in an FDA warning as recently as 13th June 2011 (http://www.medscape.com/viewarticle/744477 ).

Insulin is also far cheaper NPH insulin costs approx. 10th the price of GLP-1 analogues per month. Basal glargine or detemir cost ½ the monthly price for GLP-1.