Understanding the DUAL VII Findings in Type 2 Diabetes

Mark Warren, MD: The DUAL VII trial was fascinating. They took patients who were not controlled on basal insulin, they randomized them to receive either multiple daily injections with a basal plus a prandial short-acting insulin or a combination with liraglutide and degludec. A1C reduction was the same. They went from about 8.2% down to 6.6%, yet how they got there was very different. There was weight loss with the combination liraglutide and degludec versus weight gain with multiple daily injections. There was much more hypoglycemia with multiple daily injections, but anywhere from 80% to 90% reduction in hypoglycemia events with the combination of liraglutide and degludec. And their glycemic control was equal, but the group with the combination was 1 shot a day, while the other group was 4 shots a day.

The DUAL VII trial showed us that we could get equal glycemic control using 1 shot of a combination GLP-1 receptor agonist and a basal insulin versus taking 4 shots a day, multiple daily injections, with basal and bolus insulin. Equal, great glycemic control and A1Cs under 6.7% with less hypoglycemia, weight loss instead of weight gain, and fewer injections, those are all wins when we’re talking with our patients about intensifying their basal regimen. They’re all concerned about hypoglycemia, multiple daily injections, and weight gain. So, with this combination, we’re able to do it with 1 shot and without the weight gain or the hypoglycemia we’d expect with multiple daily injections.

At the end of the trial, the dose of the basal insulin with degludec in combination with liraglutide was around 40 units versus around 80 to 85 units with the combination of the bolus insulin and basal multiple daily injections. The total insulin dose was, again, about half what you saw with the multiple daily injections. So, I think that does help us as far as weight gain, hypoglycemia, and the cost of the basal insulin.

The DUAL VII trial showed us that, even up to 85 units of total insulin, we were able to achieve equal control with almost half as much insulin or approximately half as much insulin. And that’s because that the GLP-1 receptor agonist effect is so great with type 2 diabetes. It’s impossible to get good glycemic control with just a basal insulin. And if you don’t go with the multiple daily injections, you need to add a GLP-1 receptor agonist. It just shows the importance of GLP-1 and the incretin effect in diabetes.