Add-On Insulin Glargine Better Than Rosiglitazone in Type 2 Diabetes

Best to add glargine rather then rosiglitazone for type 2 patients inadequately controlled on dual oral therapy with sulfonylurea and metformin. Three antiglycemic agents are often required as type 2 diabetes advances, Dr. Julio Rosenstock and his colleagues note in their report. However, the risks and benefits have to be weighed when adding a third agent to an ineffective dual-therapy regimen.
To assess the relative benefits of adding rosiglitazone (Avandia) versus insulin glargine (Lantus), Dr. Rosenstock, from the Dallas Diabetes and Endocrine Center in Texas, and his team enrolled 217 patients with hemoglobin A1C levels between 7.5% and 11% while on a sulfonylurea and metformin for at least 3 months, and a BMI > 25.

Patients were randomly assigned to insulin glargine, initiated at 10 IU/day at bedtime, titrated up to a target fasting plasma glucose (FPG) level of no more than 120 mg/dL (n = 104). The remaining 112 subjects were assigned rosiglitazone started at 4 mg/day and increased to a maximum of 8 mg/day. (One patient was excluded for lack of data.)

During the 24-week study, A1C was reduced by 1.66% in the insulin group and by 1.51% in the rosiglitazone group, not a significant difference. However, for baseline A1C levels of 9.5% or higher, insulin was more effective. Insulin reduced FPG by 64.9 mg/dL compared with 46.3 mg/dL in the rosiglitazone group (p = 0.001).

Total cholesterol, LDL cholesterol, and triglycerides decreased during insulin use and increased during rosiglitazone use. None of those treated with insulin developed edema, compared with 12.5% of those using rosiglitazone. Rosiglitazone was also associated with greater weight gain (3.0 versus 1.7 kg).

The average rate of hypoglycemic events (< 70 mg/dL) per patient-year after adjusting for BMI was 7.7 with insulin and 3.4 with rosiglitazone (p = 0.0073).

The authors estimate that the total cost of drugs, syringes and monitoring supplies over 24 weeks averaged $1368 in the insulin group and $1603 in the rosiglitazone group.

"These results provide solid clinical evidence for the decision-making process needed to select a third antidiabetic agent when dual therapy is deemed inadequate in the complex setting of worsening type 2 diabetes," Dr. Rosenstock and his team conclude.
Diabetes Care 2006;29:554-559.

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