Glycaemic efficacy and safety of linagliptin compared to a basal-bolus insulin regimen in patients with type 2 diabetes undergoing non-cardiac surgery: A multicentre randomized clinical trial

• Authors: Priyathama Vellanki, Emory University; Neda Rasouli, University of Colorado; David Baldwin, Rush University; Sara Alexanian, Boston University; Isabel Anzola, Emory University; Maria Urrutia, Emory University; Saumeth Cardona, Emory University; Limin Peng, Emory University; Francisco Pasquel, Emory University; Guillermo Umpierrez, Emory University; J Haw, Emory University; Maya Fayfman, Emory University
• Journal Title: Diabetes Obesity & Metabolism
• Volume: Volume 21, Number 4
• Publisher: Wiley | 2019-04-01, Pages 837-843
• Type of Work: Article | Post-print: After Peer Review
• Publisher DOI: http://doi.org/10.1111/dom.13587
• Subjects: Biology, Biostatistics; Health Sciences, Public Health; Health Sciences, Medicine and Surgery
• Keywords: Science & Technology; Life Sciences & Biomedicine; Endocrinology & Metabolism; DPP-IV inhibitor; glycaemic control; incretin therapy; randomised trial; Critically ill; Glucose control; Hospitalized patients; Inpatient management; General medicine; Hyperglycemia; Therapy; Mortality; Sitagliptin; Infection

Abstract

Aims: The use of incretin-based therapy, rather than or complementary to, insulin therapy is an active area of research in hospitalized patients with type 2 diabetes (T2D). We determined the glycaemic efficacy and safety of linagliptin compared to a basal-bolus insulin regimen in hospitalized surgical patients with T2D. Materials and Methods: This prospective open-label multicentre study randomized T2D patients undergoing non-cardiac surgery with admission blood glucose (BG) of 7.8 to 22.2 mmol/L who were under treatment with diet, oral agents or total insulin dose (TDD) ≤ 0.5 units/kg/day to either linagliptin (n = 128) daily or basal-bolus (n = 122) with glargine once daily and rapid-acting insulin before meals. Both groups received supplemental insulin for BG > 7.8 mmol/L. The primary endpoint was difference in mean daily BG between groups. Results: Mean daily BG was higher in the linagliptin group compared to the basal-bolus group (9.5 ± 2.6 vs 8.8 ± 2.3 mmol/L/dL, P = 0.03) with a mean daily BG difference of 0.6 mmol/L (95% confidence interval 0.04, 1.2). In patients with randomization BG < 11.1 mmol/L (63% of cohort), mean daily BG was similar in the linagliptin and basal-bolus groups (8.9 ± 2.3 vs 8.7 ± 2.3 mmol/L, P = 0.43); however, patients with BG ≥ 11.1 mmol/L who were treated with linagliptin had higher BG compared to the basal-bolus group (10.9 ± 2.6 vs 9.2 ± 2.2 mmol/L, P < 0.001). Linagliptin resulted in fewer hypoglycaemic events (1.6% vs 11%, P = 0.001; 86% relative risk reduction), with similar supplemental insulin and fewer daily insulin injections (2.0 ± 3.3 vs 3.1 ± 3.3, P < 0.001) compared to the basal-bolus group. Conclusions: For patients with T2D undergoing non-cardiac surgery who presented with mild to moderate hyperglycaemia (BG < 11.1 mmol/L), daily linagliptin is a safe and effective alternative to multi-dose insulin therapy, resulting in similar glucose control with lower hypoglycaemia.