Intense simplified strategy for newly diagnosed type 2 diabetes in patients with severe hyperglycaemia: multicentre, open label, randomised trial
Authors: Liu Liehua , Ke Weijian , Li Hai , Li Fangping , Fan Guanjie , Kuang Jian , Ma Jianhua , Zhang Xiuwei , Ji Bing , Li Shu , Du Yinghong , Xue Yaoming , Lyu Zhaohui , Gao Leili , Qu Shen , Shi Yongquan , Yan Li , Deng Wanping , Xu Chaoyan , Dai Peiji , Xu Lijuan , Liu Juan , Wan Xuesi , Wei Guohong , Yu Shuang , Hong Shubin , Zhang Pengyuan , Huang Zhimin , Cao Xiaopei , Liao Zhihong , Xiao Haipeng , Mu Yiming , Handelsman Yehuda , Li Yanbing 
Published: October 2024

Abstract

Objective
To evaluate whether the intense simplified strategy, which comprises short term intensive insulin therapy (SIIT) followed by subsequent oral antihyperglycaemic regimens, could improve long term glycaemic outcomes in patients with newly diagnosed type 2 diabetes mellitus and severe hyperglycaemia.

Design
Multicentre, open label, randomised trial.

Setting
15 hospitals in China between December 2017 and December 2020.

Participants

412 patients with newly diagnosed type 2 diabetes and significant hyperglycaemia (HbA
1c
≥8.5%).

Interventions
All randomised participants initially received SIIT for 2-3 weeks, followed by linagliptin 5 mg/day, metformin 1000 mg/day, combination linagliptin plus metformin, or lifestyle modification alone (control) for 48 weeks.

Main outcome measures

The primary outcome was the percentage of participants achieving HbA
1c
<7.0% at week 48 after SIIT. Secondary outcomes included glycaemic control, β cell function, and variations in insulin sensitivity.

Results

412 participants were randomised. At baseline, the mean age was 46.8 (standard deviation 11.2) years, mean body mass index was 25.8 (2.9), and mean HbA
1c
was 11.0% (1.9%). At week 48, 80% (78/97), 72% (63/88), and 73% (69/95) of patients in the linagliptin plus metformin, linagliptin, and metformin groups, respectively, achieved HbA
1c
<7.0%, compared with 60% (56/93) in the control group (P=0.02 overall; P=0.003 for linagliptin plus metformin versus control; P=0.12 for linagliptin versus control; P=0.09 for metformin versus control). Additionally, 70% (68/97), 68% (60/88), and 68% (65/95) of patients in the linagliptin plus metformin, linagliptin, and metformin group, respectively, achieved HbA
1c
<6.5% compared with 48% (45/93) in the control group (P=0.005 overall; P=0.005 for linagliptin plus metformin versus control; P=0.01 for linagliptin versus control; P=0.008 for metformin versus control; all were significant after adjustment for multiple comparisons). Thus, compared with the control group, participants in the linagliptin plus metformin group were more likely to achieve HbA
1c
<7.0% at week 48 (odds ratio 2.78, 95% confidence interval 1.37 to 5.65; P=0.005). Moreover, the linagliptin plus metformin group showed the most significant improvement in fasting plasma glucose and β cell function indices. All treatments were well tolerated.

Conclusions
The intense simplified strategy using subsequent oral therapies post-SIIT, especially the linagliptin plus metformin combination, sustainably improved glycaemic control and β cell function in patients with newly diagnosed type 2 diabetes mellitus and severe hyperglycaemia. This approach offers a promising direction for decision making in the clinical management of type 2 diabetes mellitus.

Trial registration

ClinicalTrials.gov
NCT03194945