title: When Intensive Insulin Therapy (MDI) Fails in Patients With Type 2 Diabetes: Switching to GLP-1 Receptor Agonist Versus Insulin Pump.
abstract: Treatment with insulin, alone or with oral or injectable hypoglycemic agents, is becoming increasingly common in patients with type 2 diabetes. However, approximately 40% of patients fail to reach their glycemic targets with the initially prescribed regimen and require intensification of insulin therapy, which increases the risks of weight gain and hypoglycemia. Many of these patients eventually reach a state in which further increases in the insulin dosage fail to improve glycemic control while increasing the risks of weight gain and hypoglycemia. The recently completed OpT2mise clinical trial showed that continuous subcutaneous insulin infusion (CSII) is more effective in reducing glycated hemoglobin (HbA1c) than intensification of multiple daily injection (MDI) insulin therapy in patients with type 2 diabetes who do not respond to intensive insulin therapy. CSII therapy may also be useful in patients who do not reach glycemic targets despite multidrug therapy with basal-bolus insulin and other agents, including glucagon-like peptide (GLP)-1 receptor agonists; current guidelines offer no recommendations for the treatment of such patients. Importantly, insulin and GLP-1 receptor agonists have complementary effects on glycemia and, hence, can be used either sequentially or in combination in the initial management of diabetes. Patients who have not previously failed GLP-1 receptor agonist therapy may show reduction in weight and insulin dose, in addition to moderate improvement in HbA1c, when GLP-1 receptor agonist therapy is added to MDI regimens. In subjects with long-standing type 2 diabetes who do not respond to intensive insulin therapies, switching from MDI to CSII and/or the addition of GLP-1 receptor agonists to MDI have the potential to improve glycemic control without increasing the risk of adverse events.
authors.affiliation: Sheba Medical Center, Tel Hashomer, Israel ohad.cohen@sheba.health.gov.il.
authors.forename: Ohad
authors.initials: O
authors.lastname: Cohen
authors.affiliation: Dipartimento di Medicina Interna e Specialità Mediche, Sapienza University, Rome, Italy.
authors.forename: Sebastiano
authors.initials: S
authors.lastname: Filetti
authors.affiliation: Medtronic Bakken Research Center, Maastricht, the Netherlands.
authors.forename: Javier
authors.initials: J
authors.lastname: Castañeda
authors.affiliation: Dipartimento di Medicina Interna e Specialità Mediche, Sapienza University, Rome, Italy.
authors.forename: Marianna
authors.initials: M
authors.lastname: Maranghi
authors.affiliation: Department of Internal Medicine, Bronx-Lebanon Hospital, Bronx, NY, and Center for Diabetes Care, Tel Aviv, Israel.
authors.forename: Mariela
authors.initials: M
authors.lastname: Glandt
mesh_terms: D001786:Blood Glucose / Q000187:drug effects; D001835:Body Weight / Q000187:drug effects; D003922:Diabetes Mellitus, Type 1 / Q000097:blood / Q000188:drug therapy; D003924:Diabetes Mellitus, Type 2 / Q000097:blood / Q000188:drug therapy*; D057915:Drug Substitution; D006442:Glycated Hemoglobin / Q000032:analysis; D006801:Humans; D007003:Hypoglycemia / Q000139:chemically induced; D007004:Hypoglycemic Agents / Q000008:administration & dosage* / Q000009:adverse effects; D007279:Injections, Subcutaneous; D007328:Insulin / Q000008:administration & dosage* / Q000009:adverse effects; D007332:Insulin Infusion Systems; D017211:Treatment Failure; D015430:Weight Gain / Q000187:drug effects; D000097789:Glucagon-Like Peptide-1 Receptor Agonists
chemical_list: D001786:Blood Glucose; D006442:Glycated Hemoglobin; D007004:Hypoglycemic Agents; D007328:Insulin; D000097789:Glucagon-Like Peptide-1 Receptor Agonists