Summary:
In 1,748 adults with T2D (HbA1c 7.5-10.0%) inadequately controlled on basal insulin glargine and metformin, once-weekly semaglutide 1.0 mg for 52 weeks achieved greater HbA1c reduction (1.5% vs 1.2%, P<0.0001), weight loss vs gain (4.1 kg loss vs 2.8 kg gain, difference 7 kg), and more reaching target (<7%: 40.4% vs 30.2%) compared to thrice-daily insulin aspart, with dramatically lower clinically significant hypoglycemia (15.9% vs 43.4%, P<0.0001) but more GI side effects (nausea 14.8% vs 0.8%).
| PICO | Description |
|---|---|
| Population | 1,748 adults with T2D (HbA1c 7.5-10.0%) on basal insulin glargine + metformin, 21 countries. |
| Intervention | Once-weekly semaglutide 1.0 mg added to basal insulin + metformin for 52 weeks. |
| Comparison | Thrice-daily insulin aspart (dose-titrated) added to basal insulin + metformin. |
| Outcome | HbA1c -1.5% vs -1.2%. Weight difference 7 kg. Hypoglycemia 15.9% vs 43.4%. |
Clinical Context
Many T2D patients require intensification beyond basal insulin. Traditional approach (prandial insulin) is effective but burdensome with hypoglycemia and weight gain.
Clinical Pearls
1. The 7 kg Weight Differential Is Transformative: -4.1 kg vs +2.8 kg profoundly impacts metabolic health.
2. Hypoglycemia Risk Reduction Is Dramatic: Nearly three-fold lower (15.9% vs 43.4%).
3. Glycemic Control Was Superior Despite Simpler Regimen: Once-weekly vs thrice-daily.
4. Cardiovascular Risk Factors Favored Semaglutide: SBP reduced 3.0 mmHg vs increased 0.9 mmHg.
Practical Application
Consider semaglutide as first-line intensification for most patients on basal insulin. Monitor for hypoglycemia and reduce basal insulin as needed.
Study Limitations
Open-label design. 52-week duration. Cost and access barriers to GLP-1 RAs.
Bottom Line
Semaglutide is superior to prandial insulin aspart for basal insulin intensification with better control, 7 kg weight advantage, and dramatic hypoglycemia reduction.
Source: Kellerer M, et al. “Semaglutide vs Insulin Aspart Added to Basal Insulin in T2D (SUSTAIN 11).” Diabetes Obes Metab, 2022. Read article
