Hospital Pharmacy - May 2017 - 375

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Baker

Comparative Efficacy
Indication: Type 2 Diabetes Mellitus
Guidelines
Guideline: Standards of medical care in diabetes-2017
Reference: American Diabetes Association4,5
Comments: The choice of antidiabetic drug should be
based on a patient-centered approach. The preferred initial pharmacologic agent for treatment of type 2 diabetes
is metformin, if not contraindicated and if tolerated. In
patients receiving long-term metformin therapy, periodic
measurement of B12 levels should be considered and supplementation given as needed. Insulin should be considered as initial therapy in patients newly diagnosed with
type 2 diabetes who are symptomatic and/or have hemoglobin A1c (HbA1c) 10% or higher and/or blood glucose
levels of 300 mg/dL or higher. In patients with established
cardiovascular disease, treatment with empagliflozin or
liraglutide should be considered.
Guideline: Oral pharmacologic treatment of type 2 diabetes mellitus: A clinical practice guideline update from
the American College of Physicians
Reference: American College of Physicians6
Comments: If not contraindicated and if tolerated, metformin is the preferred agent for treatment of type 2 diabetes when pharmacologic therapy is needed to improve
glycemic control; metformin is for use in addition to lifestyle modifications. The choice to add another antidiabetic drug (eg, sulfonylurea, thiazolidinedione, sodium
glucose cotransporter 2 inhibitor, dipeptidyl peptidase 4
[DPP-4] inhibitor) to metformin should be based on a
patient-centered approach, taking into consideration the
benefits, adverse effects, and costs. The guidelines only
evaluated oral drugs and do not mention insulin or GLP-1
receptor agonists.
Studies
Drug: Insulin Degludec/Liraglutide versus Insulin
Degludec or Liraglutide
Reference: Gough SC, et al, 2014 (DUAL I trial)7
Study Design: Phase 3, randomized, open-label, multicenter study
Study Funding: Novo Nordisk
Patients: 1663 insulin-naive adults (18 years and older)
with type 2 diabetes, HbA1c 7% to 10%, and body mass
index (BMI) of 40 kg/m2 or less. Patients had previously
been treated with metformin with or without pioglitazone
for at least 90 days. Patients were excluded if they had
received treatment with GLP-1 receptor agonists, DPP-4
inhibitors, or sulfonylureas within 90 days of screening.
Mean patient age was 55 years, mean HbA1c was 8.3%,
and mean BMI was 31.2 kg/m2. Median metformin and

pioglitazone dosages were similar among the 3 groups at
baseline and did not change during the study. About 83%
of patients were receiving metformin at baseline, and
17% were receiving metformin plus pioglitazone.
Intervention: Patients were randomized (2:1:1) to receive a
once-daily subcutaneous injection of insulin degludec/liraglutide (n = 834), insulin degludec (n = 414), or liraglutide (n
= 415) for 26 weeks. The dose in all 3 groups was adjusted
based on glycemic control. Insulin degludec/liraglutide was
administered at the same time each day; the dosage regimen
was titrated twice weekly to achieve a fasting blood glucose
of 72 to 90 mg/dL. Metformin or pioglitazone was continued
unchanged, unless documented safety reasons warranted a
dosage adjustment.

Results
Primary Endpoint(s)
** The mean reduction in HbA1c was −1.9% with insulin
degludec/liraglutide, −1.4% with insulin degludec,
and −1.3% with liraglutide at week 26, with insulin
degludec/liraglutide meeting criteria for noninferiority to insulin degludec (estimated treatment difference, −0.47% [95% confidence interval, CI, −0.58%
to −0.36%]; P < .001) and meeting criteria for superiority to liraglutide (estimated treatment difference,
−0.64% [95% CI, −0.75% to −0.53%]; P < .001).
HbA1c at the end of treatment was 6.4% with insulin
degludec/liraglutide, 6.9% with insulin degludec, and
7% with liraglutide.

Secondary Endpoint(s)
** Achievement of HbA1c less than 7% at week 26
occurred in 81% of patients with insulin degludec/
liraglutide, 65% with insulin degludec, and 60% with
liraglutide; the number needed to treat (NNT) was 7
versus insulin degludec and 5 versus liraglutide. The
odds ratio (OR) was 2.38 (95% CI, 1.78-3.18; P <
.001) for insulin degludec/liraglutide versus insulin
degludec and 3.26 (95% CI, 2.45-4.33; P < .001) for
insulin degludec/liraglutide versus liraglutide.
** Achievement of HbA1c less than 6.5% at week 26
occurred in 70% of patients with insulin degludec/
liraglutide, 47% with insulin degludec, and 41%
with liraglutide; NNT was 5 versus insulin degludec
and 4 versus liraglutide. The OR was 2.82 (95% CI,
2.17-3.67; P < .001) for insulin degludec/liraglutide
versus insulin degludec and 3.98 (95% CI, 3.055.18; P < .001) for insulin degludec/liraglutide versus liraglutide.
** Insulin degludec/liraglutide therapy was associated
with a 0.5-kg weight loss, insulin degludec with a
1.6-kg weight gain, and liraglutide with a 3-kg



Table of Contents for the Digital Edition of Hospital Pharmacy - May 2017

Editorial, For Sale: FDA Priority Review Vouchers
Current FDA-Related Drug Information; Approvals, Submission, and Important Labeling Changes for US Marketed Pharmaceuticals
Summaries of Safety Labeling Changes Approved by the FDA: Boxed Warnings
ISMP Adverse Drug Reactions: Levofloxacin-Induced Neuroexcitation and Hallucinations Statin-Induced Muscle Rupture Mefloquine-Induced Rhabdomyolysis Methimazole-Induced
Critical Care Pharmacist Market Perceptions: Comparison of Critical Care Program Directors and Directors of Pharmacy
Capecitabine, Oxaliplatin, and Bevacizumab (BCapOx) Regimen for Metastatic Colorectal Cancer
Clinical Pharmacy Discharge Counseling Service and the Impact on Readmission Rates in High-Risk Patients
Mannitol Prescribing Practices With Cisplatin Before and After an Educational Newsletter Intervention
Pharmacists’ Knowledge of the Cost of Laboratory Testing
Adverse Drug Reaction Reporting Practices Among United Arab Emirates Pharmacists and Prescribers
Postoperative Pain Management With Liposomal Bupivacaine in Patients Undergoing Orthopedic Knee and Hip Arthroplasty at a Community Hospital
Formulary Drug Reviews
Hospital Pharmacy - May 2017 - 317
Hospital Pharmacy - May 2017 - 318
Hospital Pharmacy - May 2017 - 319
Hospital Pharmacy - May 2017 - 320
Hospital Pharmacy - May 2017 - 321
Hospital Pharmacy - May 2017 - 322
Hospital Pharmacy - May 2017 - 323
Hospital Pharmacy - May 2017 - Editorial, For Sale: FDA Priority Review Vouchers
Hospital Pharmacy - May 2017 - 325
Hospital Pharmacy - May 2017 - Current FDA-Related Drug Information; Approvals, Submission, and Important Labeling Changes for US Marketed Pharmaceuticals
Hospital Pharmacy - May 2017 - Summaries of Safety Labeling Changes Approved by the FDA: Boxed Warnings
Hospital Pharmacy - May 2017 - 328
Hospital Pharmacy - May 2017 - 329
Hospital Pharmacy - May 2017 - ISMP Adverse Drug Reactions: Levofloxacin-Induced Neuroexcitation and Hallucinations Statin-Induced Muscle Rupture Mefloquine-Induced Rhabdomyolysis Methimazole-Induced
Hospital Pharmacy - May 2017 - 331
Hospital Pharmacy - May 2017 - 332
Hospital Pharmacy - May 2017 - 333
Hospital Pharmacy - May 2017 - Critical Care Pharmacist Market Perceptions: Comparison of Critical Care Program Directors and Directors of Pharmacy
Hospital Pharmacy - May 2017 - 335
Hospital Pharmacy - May 2017 - 336
Hospital Pharmacy - May 2017 - 337
Hospital Pharmacy - May 2017 - 338
Hospital Pharmacy - May 2017 - 339
Hospital Pharmacy - May 2017 - 340
Hospital Pharmacy - May 2017 - Capecitabine, Oxaliplatin, and Bevacizumab (BCapOx) Regimen for Metastatic Colorectal Cancer
Hospital Pharmacy - May 2017 - 342
Hospital Pharmacy - May 2017 - 343
Hospital Pharmacy - May 2017 - 344
Hospital Pharmacy - May 2017 - 345
Hospital Pharmacy - May 2017 - 346
Hospital Pharmacy - May 2017 - 347
Hospital Pharmacy - May 2017 - Clinical Pharmacy Discharge Counseling Service and the Impact on Readmission Rates in High-Risk Patients
Hospital Pharmacy - May 2017 - 349
Hospital Pharmacy - May 2017 - 350
Hospital Pharmacy - May 2017 - 351
Hospital Pharmacy - May 2017 - 352
Hospital Pharmacy - May 2017 - Mannitol Prescribing Practices With Cisplatin Before and After an Educational Newsletter Intervention
Hospital Pharmacy - May 2017 - 354
Hospital Pharmacy - May 2017 - 355
Hospital Pharmacy - May 2017 - 356
Hospital Pharmacy - May 2017 - Pharmacists’ Knowledge of the Cost of Laboratory Testing
Hospital Pharmacy - May 2017 - 358
Hospital Pharmacy - May 2017 - 359
Hospital Pharmacy - May 2017 - 360
Hospital Pharmacy - May 2017 - Adverse Drug Reaction Reporting Practices Among United Arab Emirates Pharmacists and Prescribers
Hospital Pharmacy - May 2017 - 362
Hospital Pharmacy - May 2017 - 363
Hospital Pharmacy - May 2017 - 364
Hospital Pharmacy - May 2017 - 365
Hospital Pharmacy - May 2017 - 366
Hospital Pharmacy - May 2017 - Postoperative Pain Management With Liposomal Bupivacaine in Patients Undergoing Orthopedic Knee and Hip Arthroplasty at a Community Hospital
Hospital Pharmacy - May 2017 - 368
Hospital Pharmacy - May 2017 - 369
Hospital Pharmacy - May 2017 - 370
Hospital Pharmacy - May 2017 - 371
Hospital Pharmacy - May 2017 - 372
Hospital Pharmacy - May 2017 - 373
Hospital Pharmacy - May 2017 - Formulary Drug Reviews
Hospital Pharmacy - May 2017 - 375
Hospital Pharmacy - May 2017 - 376
Hospital Pharmacy - May 2017 - 377
Hospital Pharmacy - May 2017 - 378
Hospital Pharmacy - May 2017 - 379
Hospital Pharmacy - May 2017 - 380
Hospital Pharmacy - May 2017 - 381
Hospital Pharmacy - May 2017 - 382
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