ACHIEVING BEST PRACTICE
SA JOURNAL OF DIABETES & VASCULAR DISEASE
withdrawal of the drug. In a report on observed adverse events up
to December 2007, only 0.27 events per 1 000 patient years were
recorded.
6
The assessment of long-term cost effectiveness of exenatide
in this cohort of patients must include the lower cost of reduced
Figure 4.
ADA/EASD Algorithm for the metabolic management of type 2
diabetes. Reinforce lifestyle interventions at every visit. Check
HbA
1c
every three months until HbA
1c
is
<
7% and then at least
every six months. The interventions should be changed if HbA
1c
is
≥
7%. *Sulfonylureas other than glibenclamide (glyburide)
or chlorpropamide. **Insufficient clinical use to be confident
regarding safety.
At Diagnosis:
Lifestyle
+
metformin
Lifestyle
+
metformin
+
Intensive insulin
Lifestyle
+
metformin
+
Pioglitazone
Lifestyle
+
metformin
+
GLP – 1 agonist
Lifestyle
+
metformin
+
Pioglitazone
+
Sulfonylurea
Lifestyle
+
metformin
+
Basal insulin
Tier 2: Less well-validated therapies
Step 1
Step 2
Step 3
dosages of insulin therapy. Several of the patients could reduce
their insulin dosages significantly and this effect was seen within six
months of therapy. All the patients were on 5 mcg subcutaneously
twice a day for a month, and then increased to a dosage of 10 mcg
twice a day. Some patients had started receiving exenatide close to
the time it became unavailable, and their benefit was anecdotal.
If we consider the ADA/EASD algorithm for treatment of T2DM
(Fig. 4), tier 2 includes the less well-supported options of treatment,
including the incretin mimetics. At this stage, in the difficult-to-
manage obese patient where higher dosages of insulin will simply
result in more weight gain, these agents do provide us with an
alternative. The high cost of exenatide must be compared to the
cost of insulin and not simply add-on to failed oral therapy. As
newer therapies become available, we can only trust that costs will
not be prohibitive to the excellent clinical benefits possible with
these drugs.
References
1.
Diamant M, Van Gaal L, Stranks S,
et al
. Once weekly exenatide compared with
insulin glargine titrated to target in patients with type 2 diabetes (DURATION-3):
an open-label randomised trial.
Lancet
2010;
375
: 2234–2243.
2.
Mudaciar SM, Henry RR. Incretin mimetics and incretin-enhancing therapies. In:
Liebovitz, H, ed.
Therapy for diabetes mellitus and related disorders.
ADA 2009:
290–300.
3.
Levien TL, Baker DE. New drugs in development for the treatment of diabetes.
Diabetes Spect
2010;
22
: 92–106.
4.
Bunck MC, Diamant M, Corner A,
et al.
One-year treatment with exenatide
improves
β
-cell function, compared with insulin glargine, in metformin treated
type 2 diabetic patients.
Diabetes Care
2009;
32
: 762–768.
5.
Sherwin RS. Pharmacotherapy in diabetes: When do we use a new drug? 56th
Annual Advanced Postgraduate Course of ADA Professional Education, Feb
2009: 3–22.
6.
Comments: Exenatide and rare adverse events.
N Engl J Med
2008;
358
: 1969–
1972.
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