Switching From Insulin Bolus Treatment to GLP-1 RAs Added to Continued Basal Insulin in People With Type 2 Diabetes on Basal-Bolus Insulin

Abstract

In this issue of Diabetes Care , Rosenstock et al. (1) present successful substitution of prandial insulin with the long-acting glucagon-like peptide 1 receptor agonist (GLP-1 RA) albiglutide in the majority of a large group of people with type 2 diabetes (T2D) previously on basal-bolus (BB) insulin. The authors demonstrate that discontinuation of prandial insulin, either in total or in part, with add-on of albiglutide once per week while continuing titrated basal insulin (BI) improves glycemic control similarly to optimization of BB, reduces the risk for hypoglycemia, lowers body weight, and simplifies the insulin regimen, with improved patient-related outcomes. Before this study, the possibility of successful add-on of a GLP-1 RA, either short- (2,3) or long-acting (4,5), as alternative to prandial insulin was demonstrated in people on BI who needed treatment for prandial control. Two relatively small studies reported some advantages with addition of a long-acting GLP-1 RA to maintained BB (6,7), but it was only the FLAT-SUGAR (FLuctuATion Reduction With inSULin and Glp-1 Added togetheR) trial that demonstrated in 102 people with T2D and high cardiovascular risk on BB that the short-acting GLP-1 RA exenatide could fully substitute for prandial insulin (8). However, it was not known whether people already on BB could switch from three daily prandial insulin injections to a weekly GLP-1 RA while continuing BI before the study by Rosenstock et al. (1). If confirmed, these new findings will lead to a change in the treatment paradigm of the presently insulin-treated T2D population, estimated worldwide to be more than 60 million patients (9), at least one-third of whom are likely on BB insulin. T2D is characterized by variable combinations of impaired insulin secretion and insulin resistance, primarily hepatic. While insulin resistance remains relatively stable over time, the progressive deterioration of …