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

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More from @drpatrickholmes

28 Jun
AMPLITUDE-O Trial
1/5
Cardiovascular outcome trial for Efpeglenatide an investigational once weekly Exendin-4 based GLP-1ra.

What are the unanswered questions
Do Exendin-based GLP-1a ⤵️ MACE❓
Do GLP-1ra ⤵️ MACE in people taking SGLT2i❓
Does GLP-1ra ⤵️ renal decline❓

#ADA2021
2/5
Main results

Efpeglenatide
⤵️3-point MACE by 27%
⤵️expanded MACE by 21%
⤵️Renal composite by 32%
⤵️MACE or non-CV death by 27%

Best data yet to suggest adding GLP-1ra to SGLT2i ⤵️MACE

@DLBHATTMD
3/5
Renal outcomes

Efpeglenatide
⤵️Renal composite
⤵️Albuminuria
⤵️eGFR slope❗️
Read 6 tweets
28 Jun
#ADA2021
1/6
✅Real world data from a 🇩🇪register of patients with ♂️#hypogonadism & #type2diabetes over 12 years!

❗️ ♂️ hypogonadism is common in T2D (≈ 50%)

⚠️@Bayer presented
⚠️ other data shown ⤴️ MACE
amjmed.com/article/S0002-…

So what did they find?
2/6

Baseline Characteristics.

🤔As you can see two very different cohorts of patients.

⚠️ High risk of unresolved bias
3/6

Changes in testosterone and glycaemic markers over time.

Testosterone therapy assoc with

⤴️ Testosterone
⤵️ HbA1c
Read 6 tweets

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