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Exenatide a Noninsulin Addition for Patients Failing Basal Insulin

Exenatide twice daily shows similar glycemic control with weight loss and less hypoglycemia as compared to mealtime insulin…

Some patients with advanced type 2 diabetes still do not achieve glycemic control with insulin glargine and metformin. Mealtime insulin lispro is often added on to the regimen but it is associated with weight gain and hypoglycemia.

A randomized, multicenter, open label study was conducted in type 2 diabetes patients 18 years or older, treated with insulin glargine and metformin +/- sulfonylurea with HbA1c of 7-10%, and BMI of 25-46 kg/m2. The primary outcome was compared to the difference in HbA1c between exenatide 10-20 mcg twice daily or lispro three times daily added to glargine in inadequately controlled patients. The secondary outcome included weight, percentage of patients achieving HbA1c of 6.5% or less, insulin dose, blood pressure, and lipid measurements.

At 30 weeks, HbA1c changes were similar for exenatide (-1.13%) and insulin lispro (-1.10%). However, fasting glucose was lower with exenatide than lispro (6.5 vs 7.2 mmol/L; P=0.002). Weight decreased with exenatide (-2.5kg) and increased with lispro (+2.1kg). (P<0.001). Exenatide is well tolerated but more gastrointestinal adverse events than lispro.

In conclusion, patients with type 2 diabetes that unable to achieve glycemic control, adding exenatide before two large meals improved glycemic control similar to mealtime insulin lispro. Similar HbA1c changes with exenatide versus insulin lispro however exenatide had a greater fasting glucose reduction compared to insulin lispro. Plus, exenatide was associated with less hypoglycemia, weight loss and reduced systolic blood pressure. Adding a short acting glucagon like peptide 1 receptor agonist, exenatide, to basal insulin may be preferred over mealtime and basal insulin for some patients with type 2-diabetes.

Practice Pearls:

  • In inadequately controlled type 2 diabetes patients, adding exenatide is more beneficial over mealtime insulin lispro for the improved glycemic control and reduced weight.
  • Exenatide is associated with less hypoglycemia, more weight loss, and improved treatment satisfaction in advanced type 2-diabetes.
  • Exenatide, like insulin, requires injection, it is also has fixed dosing, fewer daily injections, and less need for glucose monitoring.

Diabetes Care (Glucagon-Like Peptide 1 Receptor Agonist or Bolus Insulin With Optimized Basal Insulin in Type 2-Diabetes). October 24. Vol. 37 no. 10 2763-2773 “http://care.diabetesjournals.org/content/37/10/2763.full”