Incretin mimetics and sodium-glucose co-transporter 2 inhibitors as monotherapy or add-on to metformin for treatment of type 2 diabetes: a systematic review and network meta-analysis

• Published in: Acta diabetologica Vol. 58; no. 1; pp. 5 - 18
• Main Authors: Jia, Shubing, Wang, Zhiying, Han, Ruobing, Zhang, Zinv, Li, Yuping, Qin, Xiaotong, Zhao, Mingyi, Xiang, Rongwu, Yang, Jingyu
• Format: Journal Article
• Language: English
• Published: Milan Springer Milan 2021; Springer Nature B.V
• Subjects: Antidiabetics; Clinical Trials as Topic - statistics & numerical data; Diabetes; Diabetes mellitus (non-insulin dependent); Diabetes Mellitus, Type 2 - blood; Diabetes Mellitus, Type 2 - complications; Diabetes Mellitus, Type 2 - drug therapy; Diabetes Mellitus, Type 2 - epidemiology; Dipeptidyl-Peptidase IV Inhibitors - therapeutic use; Drug Therapy, Combination; Glucose transporter; Glycated Hemoglobin A - drug effects; Glycated Hemoglobin A - metabolism; Hemoglobin; Humans; Hypoglycemia; Hypoglycemia - chemically induced; Hypoglycemia - epidemiology; Hypoglycemic Agents - therapeutic use; Incretins - therapeutic use; Internal Medicine; Medicine; Medicine & Public Health; Meta-analysis; Metabolic Diseases; Metformin; Metformin - administration & dosage; Metformin - adverse effects; Network Meta-Analysis; Review Article; Safety; Sodium-Glucose Transporter 2 Inhibitors - administration & dosage; Sodium-Glucose Transporter 2 Inhibitors - therapeutic use; Treatment Outcome; Type 2 diabetes; Dipeptidyl peptidase-4 inhibitor; Sodium-glucose cotransporter-2 inhibitor; Network meta-analysis; Glucagon-like peptide-1 receptor agonist
• ISSN: 0940-5429; 1432-5233
• DOI: 10.1007/s00592-020-01542-4

Purpose
Although there are many different methods of treating type 2 diabetes (T2D), it is still difficult to draw coincident conclusions concerning the efficacy and safety of different classes of new drugs, and the recommendation level of them has still kept uncertain as second anti-diabetic agents. Therefore, the aim of this study was to summarize evidence on the efficacy and safety of DPP-4is, GLP-1RAs and SGLT-2is as monotherapy or add-on to metformin (Met) for treatment of T2D.
Materials and methods
We searched PubMed, Embase, Cochrane library and ClinicalTrials.gov for relevant articles in keeping with established methods using terms associated with anti-diabetic agents up to February, 2020, with no start date restriction. Weighted mean difference and risk ratios with 95% confidence intervals were calculated within traditional and network meta-analysis. Primary outcomes were the mean change in hemoglobin A1c (HbA1c), fasting plasma glucose (FPG) change and the frequency of hypoglycemic events from baseline after 12 weeks of treatment.
Results
In total, 64 eligible studies comprising 37,780 patients and 7 treatment strategies were included. The results of primary outcomes showed that GLP-1RAs were significantly more effective than DPP-4is or SGLT-2is in reducing HbA1c when add-on to Met. For FPG, both GLP-1RAs and SGLT-2is significantly reduced FPG compared with DPP-4is whether add-on to Met or not. For hypoglycemia, monotherapy has a lower risk than combination therapy except for SGLT-2is. Ranking probability analysis indicated that GLP-1RAs and SGLT-2is, respectively, reduced HbA1c and FPG most when add-on to Met. Meanwhile, GLP-1RAs took the lowest risk to induce the hypoglycemia, whereas GLP-1RAs plus Met the highest.
Conclusions
Both GLP-1RAs and SGLT-2is have their own advantages in efficacy and safety. Monotherapy is beneficial for reducing the risk of hypoglycemia. The recommendation should be a patient-centered approach when selecting treatment choices.