Levin Philip, Fan Tao, Song Xue, Nero Damion, Davis Brian, Chu Bong-Chul
Endocr Pract. 2017 Nov;23(11):1316-1324. doi: 10.4158/EP171769.OR. Epub 2017 Aug 17.
Not all patients with type 2 diabetes achieve recommended glycated hemoglobin A (A1C) levels after adequate titration of basal insulin (BI). Current intensification approaches include addition of rapid-acting insulin (RAI) or a glucagon-like peptide 1 receptor agonist (GLP-1 RA), but it is not clear which strategy results in better long-term outcomes.
This retrospective analysis of health insurance claims data in the U.S. MarketScan database compared glycemic control and healthcare resource utilization and costs 12 months after adding a GLP-1 RA to BI versus adding a RAI or increasing BI doses. Propensity score matching was used in the comparative effectiveness analysis.
A total of 8,034 patients underwent treatment intensification within 6 months of showing poor glycemic control; 4,134 patients had their BI dose adjusted, and 2,076 and 331 received RAI and GLP-1 RA, respectively. A1C changes were similar for the GLP-1 RA and RAI cohorts but higher for the GLP-1 RA versus the dose-adjustment group. The hypoglycemia rate was lower after adding GLP-1 RA versus RAI or increasing BI dose. No overall changes in utilization of healthcare resources or diabetes-related costs were observed between intensification strategies, although prescription costs were higher for the GLP-1 RA cohort.
BI in combination with GLP-1 RAs appears to be an effective intensification strategy, further reducing A1C levels and hypoglycemia frequency compared to increasing BI doses. GLP-1 RA addition also decreases hypoglycemia frequency versus BI dose increases and RAI addition, without raising overall healthcare costs.
A1C = hemoglobin A; BI = basal insulin; CAD = coronary artery disease; ED = emergency department; FPG = fasting plasma glucose; GLP-1 RA = glucagon-like peptide 1 receptor agonist; ICD-9-CM = International Classification of Diseases, Ninth Revision, Clinical Modification; NPH = neutral protamine Hagedorn; OAD = oral antidiabetes drug; PSM = propensity score matching; RAI = rapid-acting insulin; T2D = type 2 diabetes.
并非所有2型糖尿病患者在充分滴定基础胰岛素（BI）后都能达到推荐的糖化血红蛋白A（A1C）水平。当前的强化治疗方法包括加用速效胰岛素（RAI）或胰高血糖素样肽1受体激动剂（GLP-1 RA），但尚不清楚哪种策略能带来更好的长期结局。
这项对美国MarketScan数据库中医疗保险理赔数据的回顾性分析，比较了在BI基础上加用GLP-1 RA与加用RAI或增加BI剂量12个月后的血糖控制情况、医疗资源利用情况及成本。在比较有效性分析中采用了倾向评分匹配法。
共有8034例患者在血糖控制不佳的6个月内接受了强化治疗；4134例患者调整了BI剂量，2076例和331例患者分别接受了RAI和GLP-1 RA治疗。GLP-1 RA组和RAI组的A1C变化相似，但GLP-1 RA组相对于剂量调整组变化更大。加用GLP-1 RA后的低血糖发生率低于加用RAI或增加BI剂量后的情况。尽管GLP-1 RA组的处方成本较高，但强化治疗策略之间在医疗资源利用或糖尿病相关成本方面未观察到总体变化。
BI联合GLP-1 RA似乎是一种有效的强化治疗策略，与增加BI剂量相比，能进一步降低A1C水平和低血糖发生频率。与增加BI剂量和加用RAI相比，加用GLP-1 RA还能降低低血糖发生频率，且不会增加总体医疗成本。
A1C = 糖化血红蛋白A；BI = 基础胰岛素；CAD = 冠状动脉疾病；ED = 急诊科；FPG = 空腹血糖；GLP-1 RA = 胰高血糖素样肽1受体激动剂；ICD-9-CM = 《国际疾病分类，第九版，临床修订本》；NPH = 中性鱼精蛋白锌胰岛素；OAD = 口服抗糖尿病药物；PSM = 倾向评分匹配；RAI = 速效胰岛素；T2D = 2型糖尿病
