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Initial injectable therapy in type 2 diabetes: Key considerations when choosing between glucagon-like peptide 1 receptor agonists and insulin.

Authors
  • Alexopoulos, Anastasia-Stefania1
  • Buse, John B2
  • 1 Duke University Medical Center, Durham, NC, United States. Electronic address: [email protected] , (United States)
  • 2 University of North Carolina, Chapel Hill, NC, United States. , (United States)
Type
Published Article
Journal
Metabolism: clinical and experimental
Publication Date
Sep 01, 2019
Volume
98
Pages
104–111
Identifiers
DOI: 10.1016/j.metabol.2019.06.012
PMID: 31255662
Source
Medline
Language
English
License
Unknown

Abstract

Managing type 2 diabetes is complex and necessitates careful consideration of patient factors such as engagement in self-care, comorbidities and costs. Since type 2 diabetes is a progressive disease, many patients will require injectable agents, usually insulin. Recent ADA-EASD guidelines recommend glucagon-like peptide 1 receptor agonists (GLP-1 RAs) as first injectable therapy in most cases. The basis for this recommendation is the similar glycemic efficacy of GLP-1 RAs and insulin, but with GLP-1 RAs promoting weight loss instead of weight gain, at lower hypoglycemia risk, and with cardiovascular benefits in patients with pre-existing cardiovascular disease. GLP-1 RAs also reduce burden of glucose self-monitoring. However, tolerability and costs are important considerations, and notably, rates of drug discontinuation are often higher for GLP-1 RAs than basal insulin. To minimize risk of gastrointestinal symptoms patients should be started on lowest doses of GLP-1 RAs and up-titrated slowly. Overall healthcare costs may be lower with GLP-1 RAs compared to insulin. Though patient-level costs may still be prohibitive, GLP-1 RAs can replace 50-80 units of insulin daily and reduce costs associated with glucose self-monitoring. Decisions regarding initiating injectable therapy should be individualized. This review provides a framework to guide decision-making in the real-world setting. Copyright © 2019 Elsevier Inc. All rights reserved.

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