title: Patients with type 2 diabetes mellitus failing on oral agents and starting once daily insulin regimen; a small randomized study investigating effects of adding vildagliptin.
abstract: BACKGROUND
  The addition of a DDP4-inhibitor to existing insulin therapy reduces HbA1c. However, no data exist about the addition of these agents at the beginning of insulin treatment in type 2 diabetes while this could especially be interesting because it is during this period that considerable residual beta cell function is still present. The benefit of such a strategy could be a lower insulin dose required for glycemic control. The hypothesis of our study was that adding a DPP4-inhibitor at the beginning of insulin treatment could lead to less exogenous insulin requirement, a reduction of hyperinsulinemia and side effects (hypoglycemia and weight gain), less glucose variability and improvement of insulin and glucagon dynamics during a mixed meal test.
  
  
  RESULTS
  In this small clinical trial (trial registration NTR2022) 9 patients were randomized to receive vildagliptin and 6 to receive placebo in addition to start of once daily insulin treatment. Unfortunately, due to a difficult inclusion, the preset sample size of 40 patients could not be met. Median units of insulin at the end of the study was 47 U in the placebo group and 34 U in the vildagliptin group. Median glycemic variability (SD) at the end of study was 2.1 in the placebo group and 1.5 in the vildagliptin group. Median weight gain at the end of study was 3 kg in the placebo and 0.5 kg in the vildagliptin group. Occurrence of hypoglycemia was low in both groups. Insulin, C-peptide, glucose and glucagon levels were comparable during mixed meal tests.
  
  
  CONCLUSIONS
  This small randomized study did not have sufficient power to detect effects of the addition of vildagliptin to the start of once daily long-acting insulin. However in our opinion adding a DPP4-inhibitor, especially in this group remains a very interesting approach. This study could be used as a guidance for larger studies that are required to investigate the effects of this intervention on insulin requirements, glycemic variability, hypoglycemia and weight gain.
authors.affiliation: Department of Internal Medicine, University Medical Centre Utrecht, Huispostnummer, Postbus 85500 3508, Utrecht, GA F02-126, The Netherlands. w.l.greven@umcutrecht.nl.
authors.forename: Wendela Lucia
authors.initials: WL
authors.lastname: de Ranitz-Greven
authors.forename: Joline Wilhelma Johanna
authors.initials: JW
authors.lastname: Beulens
authors.forename: Lette Birgit Elisabeth Anne
authors.initials: LB
authors.lastname: Hoeks
authors.forename: Gerdien
authors.initials: G
authors.lastname: Belle-van Meerkerk
authors.forename: Douwe Hedde
authors.initials: DH
authors.lastname: Biesma
authors.forename: Harold Wessel
authors.initials: HW
authors.lastname: de Valk
mesh_terms: D000218:Adamantane / Q000008:administration & dosage / Q000031:analogs & derivatives* / Q000627:therapeutic use; D000284:Administration, Oral; D000328:Adult; D000368:Aged; D001786:Blood Glucose / Q000032:analysis; D003924:Diabetes Mellitus, Type 2 / Q000188:drug therapy*; D054873:Dipeptidyl-Peptidase IV Inhibitors / Q000008:administration & dosage* / Q000627:therapeutic use; D005260:Female; D006801:Humans; D007328:Insulin / Q000008:administration & dosage* / Q000627:therapeutic use; D008297:Male; D008875:Middle Aged; D009570:Nitriles / Q000008:administration & dosage* / Q000627:therapeutic use; D010919:Placebos; D011759:Pyrrolidines / Q000008:administration & dosage* / Q000627:therapeutic use; D000077597:Vildagliptin
chemical_list: D001786:Blood Glucose; D054873:Dipeptidyl-Peptidase IV Inhibitors; D007328:Insulin; D009570:Nitriles; D010919:Placebos; D011759:Pyrrolidines; D000077597:Vildagliptin; D000218:Adamantane