Statement 5
GLP-1 analogs (exenatide, liraglutide, lixisenatide) can take the place
of insulin in Type 2 diabetes.
GLP-1 analogs work on different pathways within the body. They can reduce appetite, regulate
gastric emptying and enhance glucose-dependent insulin secretion10. When combined with diet
and exercise interventions, reductions in HbA1c and weight can be achieved however in practice
we do not see this in all patients. Insulin, on the other hand, is effective at reducing HbA1c levels
irrespective of the level beta cell function5 Studies have shown that after nine years of diagnosis,
a substantial number, possibly the majority of patients will need the addition of insulin therapy.
No published studies were identified that compared liraglutide/lixisenatide with NPH insulin.
The comparative data below are for exenatide and insulins:
Glycaemic control
When glycaemic control with exenatide is compared with various insulin regimens, the results
are similar, suggesting non-inferiority, although very few studies evaluated NPH insulin and the
issue of non-optimisation of the insulin treatment remains a concern. Furthermore, long-term
data are not available.
Weight
Most studies have reported weight loss with exenatide compared with insulin although in routine
care, this has not always been demonstrated
Other outcome data
No studies evaluating other mortality or cardiovascular data were identified
Hypoglycemia
Hypoglycemia is perceived to be less of a problem with exanatide, but the differences in
the trials were not marked.
Both insulin and GLP-1 analogues have their individual place in the pathway of the management
of hyperglycemia and choice of agent should be directed by patient factors5.
In the right patient at the right time, GLP-1 analogues are important adjuncts to other oral
hypoglycemic agents (and insulin in some patients), and can support both weight loss and
HbA1c reduction.
However, GLP-1 analogs cannot be used instead of insulin in those patients that require insulin.
Thinking about the principles of the right time and the right patient, it is incredibly important
that we identify the right diabetes treatment to be given to the patient and review on a frequent
basis in order to ensure optimal outcomes. SIGN guidance emphasizes the need to apply careful
clinical judgment in those people with a long duration of Type 2 diabetes on established oral
glucose-lowering drugs with poor glycaemic control (>10 years) as these individuals are poorly
represented in published studies, and to ensure insulin therapy is not delayed inappropriately for
the perceived benefits of GLP-1 analogues
GLP-1 analogs (exenatide, liraglutide, lixisenatide) can take the place
of insulin in Type 2 diabetes.
GLP-1 analogs work on different pathways within the body. They can reduce appetite, regulate
gastric emptying and enhance glucose-dependent insulin secretion10. When combined with diet
and exercise interventions, reductions in HbA1c and weight can be achieved however in practice
we do not see this in all patients. Insulin, on the other hand, is effective at reducing HbA1c levels
irrespective of the level beta cell function5 Studies have shown that after nine years of diagnosis,
a substantial number, possibly the majority of patients will need the addition of insulin therapy.
No published studies were identified that compared liraglutide/lixisenatide with NPH insulin.
The comparative data below are for exenatide and insulins:
Glycaemic control
When glycaemic control with exenatide is compared with various insulin regimens, the results
are similar, suggesting non-inferiority, although very few studies evaluated NPH insulin and the
issue of non-optimisation of the insulin treatment remains a concern. Furthermore, long-term
data are not available.
Weight
Most studies have reported weight loss with exenatide compared with insulin although in routine
care, this has not always been demonstrated
Other outcome data
No studies evaluating other mortality or cardiovascular data were identified
Hypoglycemia
Hypoglycemia is perceived to be less of a problem with exanatide, but the differences in
the trials were not marked.
Both insulin and GLP-1 analogues have their individual place in the pathway of the management
of hyperglycemia and choice of agent should be directed by patient factors5.
In the right patient at the right time, GLP-1 analogues are important adjuncts to other oral
hypoglycemic agents (and insulin in some patients), and can support both weight loss and
HbA1c reduction.
However, GLP-1 analogs cannot be used instead of insulin in those patients that require insulin.
Thinking about the principles of the right time and the right patient, it is incredibly important
that we identify the right diabetes treatment to be given to the patient and review on a frequent
basis in order to ensure optimal outcomes. SIGN guidance emphasizes the need to apply careful
clinical judgment in those people with a long duration of Type 2 diabetes on established oral
glucose-lowering drugs with poor glycaemic control (>10 years) as these individuals are poorly
represented in published studies, and to ensure insulin therapy is not delayed inappropriately for
the perceived benefits of GLP-1 analogues
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