Thread by @drpatrickholmes

1/6
#ADA2021
Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study (GRADE)

Q. What next after metformin?

MET plus:
✅GLP-1ra (liraglutide)
✅Insulin(glargine)
✅SU (glimepiride)
✅DPP4i (sitagliptin)

But
😱 No SGLT2i
😱 No TZD

care.diabetesjournals.org/content/36/8/2…

2/6
Mean baseline characteristics

57 yr old
♀️36%
66%👴🏻, 20%👴🏿
BMI 34
HbA1c 7.5%
Duration of diabetes 4.2 yr

⚠️🇺🇸 only study
⚠️only 3.6% from 'Asian' descent
⚠️ So not representative to non-🇺🇸 #type2diabetes

care.diabetesjournals.org/content/42/11/…

3/6
Summary of glycaemic outcomes

🥳GLP-1ra & Basal Insulin did best

💩DPP4i did worse. In particular if baseline HbA1c>7.8%

Bottom line - I don't think DPP-4i is a good option if HbA1c >7.8% (62mmol/mol)

📷courtesy of Prof. Matthews

4/5
Summary of macrovascular outcomes

⚠️ Preliminary results only (10% cases to be adjudicated)
⚠️ Small numbers so statistical value may change❗️

🥳GLP-1ra ⤵️ "Any CVD" (MACE, hHF, UA, TIA & revasc.)

GLP-1ra ??? evidence of primary prevention ???

📷courtesy of Prof. Matthews

5/6
Other outcomes

GLP-1ra - ⤵️ wt, ⤴️🤢, ⤵️hypos
Insulin - ➡️wt, ⤴️ hypos (but not as much as SU)
SU - ⤴️ wt, ⤴️⤴️ hypos (⚠️small numbers❗️)
DPP4i - ⤵️ wt, ⤵️hypos

No difference in microvascular complications

📷courtesy of Prof. Matthews

6/6
Overall conclusions

Q. What next after metformin?

A.
🏆GLP-1ra did best
🙂Basal insulin did well
😐SU
🤬DPP4i

⚠️ No SGLT2i ❗️, results preliminary, few 'asians' glimepiride not gliclazide

Should add to future guidelines, particularly with cost-effectiveness analysis