Oral Medications Alone Effective in Type 2 Diabetes With High HbA1c

NASHVILLE, Tenn. — Clinicians can effectively treat patients with type 2 diabetes and HbA1c levels above 9% with oral medications alone, researchers reported at the American Association of Clinical Endocrinologists (AACE) 24th Annual Scientific & Clinical Congress.

Further, they noted, using oral medications alone in patients with high HbA1c levels has several advantages, including weight loss and better glycemic control, which are not observed in insulin-based regimens.

“All the patients included start with HbA1c above 9% and each of them came down to less than 7.0%,” said study author Rameck Hunt, MD who with Rutgers-Robert Wood Johnson Medical School in North Brunswick, New Jersey.

For the past 30 years, the incidence of new-onset type 2 diabetes has been steadily rising in the United States. The AACE/ACE guidelines state that insulin should be started in symptomatic patients if the patient has an HbA1c level above 9%.

However, Hunt said insulin therapy has several adverse effects, such as weight gain. In addition, he said patient resistance to initiating insulin as well as compliance can be issues.

Research has now shown that several oral medications are extremely effective in glucose control without the added adverse effects associated with insulin therapy. Some of these newer medications sensitize insulin without promoting weight gain. In fact, they promote weight loss, according to Hunt.

The researchers presented a case series of 18 patients who were diagnosed with type 2 diabetes and had an HbA1c level of 9% or greater at diagnosis. All patients were treated with oral medications exclusively or initiated oral hypoglycemics after less than 3 months of insulin therapy. 

Hunt said all the patients were able to achieve adequate glycemic control, with an HbA1c level of 7% or less, within 6 months on oral agents alone. 

In this series of patients, six had an HbA1c level of 12% or higher at diagnosis. Fifteen patients were treated with only one or two medications, and the remaining three patients required three medications.

The latest follow-up at 15 months demonstrated that 17 of the 18 patients were still successfully controlled on oral agents alone.

The researchers noted that oral medications are the initial treatment of choice for patients with lower HbA1c levels at the time of diagnosis. However, this case series suggests that patients with higher HbA1c levels should also be considered for oral therapy instead of insulin therapy.

The researchers plan to validate their findings with a double-blind, placebo-controlled trial.

“The take-home point is that insulin is a growth factor that causes weight gain and is linked to atherosclerosis, triglyceride production, fat storage, insulin resistance, etc. Therefore we should avoid using insulin too early in the treatment, as many of the people started on insulin don’t get off insulin, taking it the rest of their lives,” Hunt told Endocrinology Advisor.

“We take the opposite approach. Our approach promotes weight loss, especially now that we have newer oral medications, and it gets the patients to an HbA1c goal and better metabolic profile in terms of cholesterol, inflammatory markers, etc.”

Reference

1. Kambhampati R et al. Abstract #205. Presented at: American Association of Clinical Endocrinologists (AACE) 24th Annual Scientific & Clinical Congress; May 13-17, 2015; Nashville, Tenn.