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Clinician Article

Feasibility of Simplification From a Basal-Bolus Insulin Regimen to a Fixed-Ratio Formulation of Basal Insulin Plus a GLP-1RA or to Basal Insulin Plus an SGLT2 Inhibitor: BEYOND, a Randomized, Pragmatic Trial.



  • Giugliano D
  • Longo M
  • Caruso P
  • Di Fraia R
  • Scappaticcio L
  • Gicchino M, et al.
Diabetes Care. 2021 Apr 21. pii: dc20-2623. doi: 10.2337/dc20-2623. (Original)
PMID: 33883195
Read abstract
Disciplines
  • Endocrine
    Relevance - 6/7
    Newsworthiness - 6/7
  • Family Medicine (FM)/General Practice (GP)
    Relevance - 6/7
    Newsworthiness - 6/7
  • General Internal Medicine-Primary Care(US)
    Relevance - 6/7
    Newsworthiness - 6/7
  • Internal Medicine
    Relevance - 5/7
    Newsworthiness - 5/7

Abstract

OBJECTIVE: BEYOND trial evaluated the feasibility of either basal insulin plus glucagon-like peptide 1 receptor agonist (GLP-1RA) or basal insulin plus sodium-glucose cotransporter 2 inhibitor (SGLT2i) to replace a full basal-bolus insulin (BBI) regimen in participants with type 2 diabetes and inadequate glycemic control.

RESEARCH DESIGN AND METHODS: Participants were randomized (1:1:1) to: 1) intensification of the BBI regimen (n = 101), 2) fixed ratio of basal insulin plus GLP-1RA (fixed-combo group; n = 102), and 3) combination of basal insulin plus SGLT2i (gliflo-combo group; n = 102). The primary efficacy outcome was change from baseline in HbA1c at 6 months.

RESULTS: Baseline characteristics were similar among the three groups (mean HbA1c was 8.6% [70 mmol/mol]). At 6 months, patients experienced similar reduction in HbA1c level (-0.6 ± 0.8, -0.6 ± 0.8, and -0.7 ± 0.9%, mean ± SD, respectively; noninferiority P < 0.001 vs. BBI), and the proportion of patients with HbA1c =7.5% was also similar (34%, 28%, and 27%, respectively; P = 0.489). Total insulin dose increased in the BBI group (62 units/day) and decreased both in the fixed-combo and gliflo-combo groups (27 units/day and 21 units/day, respectively; P < 0.01). The proportion of patients with hypoglycemia was 17.8%, 7.8%, and 5.9%, respectively (P = 0.015). There were 12 dropouts in the fixed-combo group, 9 in the gliflo-combo group, and none in the BBI group.

CONCLUSIONS: BEYOND provides evidence that it is possible and safe to switch from a BBI regimen to either a once-daily fixed-combo injection or once-daily gliflozin added to basal insulin, with similar glucose control, fewer insulin doses, fewer injections daily, and less hypoglycemia.


Clinical Comments

Endocrine

While not surprising, this trial provides evidence for the benefit and safety of replacing bolus insulin with a GLP1RA or SGLT2i in patients with T2D on basal-bolus insulin regimens.

Family Medicine (FM)/General Practice (GP)

This small and quite complex trial has admitted limitations and is difficult to translate into change. I might incorporate into my practice, but some of my patients may be changed to a different regime, so this is good to know. The dropout rates in the intervention group seem high to me. I`d like to see the results with larger numbers over a longer period.

General Internal Medicine-Primary Care(US)

Not sure this is approved for weight loss, but it certainly does do that - impressively sometimes.

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