IDegLira HIGH Trial

Sponsor
Emory University (Other)
Overall Status
Completed
CT.gov ID
NCT03737240
Collaborator
Novo Nordisk A/S (Industry)
188
2
2
41.7
94
2.3

Study Details

Study Description

Brief Summary

Basal-bolus insulin therapy is recommended for patients with poorly controlled type 2 diabetes (T2D) and HbA1c >9%. However, basal-bolus insulin is labor intensive and associated with increased risk of hypoglycemia, glycemic variability, weight gain and poor compliance. Thus, there is a critical need for a simpler treatment regimen that could overcome these limitations. IDegLira, a fixed-ratio combination (FRC) therapy consisting of insulin degludec and liraglutide, is an attractive option for this population given its proven benefits on glycemic control, weight and compliance. This study aims to show that a simpler regimen using a novel FRC agent (IDegLira) can improve glycemic control, decrease hypoglycemia, reduce the burden of diabetes care, and improve satisfaction/adherence in patients with poorly controlled T2D with HbA1c between ≥ 9-12%. This open-label, treat-to- target, two-arm parallel, controlled trial will randomize participants with T2D and HbA1c ≥ 9%, treated with oral anti-diabetic agents and/or basal insulin therapy to lDegLira or basal-bolus insulin for 26 weeks.

Condition or Disease Intervention/Treatment Phase
Phase 3

Detailed Description

Extensive literature has shown that persistent hyperglycemia is associated with short- and long-term complications. Sustained hyperglycemia, also known as glucotoxicity, leads to progressive loss of beta-cell function and is considered a key pathophysiological process in the development of type 2 diabetes (T2D). Patients with severe hyperglycemia may respond poorly to oral anti-diabetic agents (OAD) alone initially and frequently require insulin to achieve glycemic targets. Current guidelines recommend to initiate therapy with basal insulin and progressively step up to basal-bolus insulin in patients with high HbA1c >9%, particularly if symptomatic or with catabolic symptoms.

A basal-bolus insulin regimen increases the risk of hypoglycemia, weight gain and glycemic variability, which are limiting factors in achieving glycemic targets. A basal-bolus insulin regimen is also labor intensive and often requires multiple daily injections, further increasing the burden of diabetes care and decreasing patient adherence. In contrast, simplified treatment plans may improve adherence, leading to glycemic targets achievement. Thus, there is a critical need for simpler regimens that could overcome clinical inertia, improve patient adherence, and decrease glycemic variability in patients with poorly controlled type 2 diabetes. This prospective randomized control trial will compare IDegLira to basal-bolus insulin regimen in achieving glycemic control, while reducing hypoglycemia, glycemic variability, and weight gain in patients with uncontrolled T2D and HbA1c ≥9%.

Study Design

Study Type:
Interventional
Actual Enrollment :
188 participants
Allocation:
Randomized
Intervention Model:
Parallel Assignment
Intervention Model Description:
Participants will be randomized in a 1 to 1 ratio to receive the study treatment or standard of care.Participants will be randomized in a 1 to 1 ratio to receive the study treatment or standard of care.
Masking:
None (Open Label)
Primary Purpose:
Treatment
Official Title:
A Randomized Controlled Trial Comparing the Safety and Efficacy of IDegLira Versus Basal Bolus in Patients With Poorly Controlled Type 2 Diabetes
Actual Study Start Date :
Jan 15, 2019
Actual Primary Completion Date :
Jul 8, 2022
Actual Study Completion Date :
Jul 8, 2022

Arms and Interventions

Arm Intervention/Treatment
Experimental: IDegLira

Participants in this group will receive IDegLira (with metformin, unless contraindicated) for 26 weeks.

Drug: IDegLira
Participants in this study arm will discontinue all other diabetes medications, except for metformin which will be continued at prescribed dose (unless contraindicated). IDegLira will be given once daily, at the same time of the day with or without food for 26 weeks. IDegLira will be titrated until the maximum dose is reached, up to the target fasting blood glucose of 70 to 100 milligrams per deciliter (mg/dL).
Other Names:
  • Xultophy 100/3.6
  • insulin degludec
  • liraglutide
  • Active Comparator: Basal-Bolus Insulin

    Participants in this group will receive basal-bolus insulin (with metformin, unless contraindicated) for 26 weeks. The basal-bolus insulin regimen includes Insulin Degludec (U-100) and Insulin Aspart.

    Drug: Insulin Degludec (U-100)
    Participants in the basal-bolus insulin study arm will discontinue all other diabetes medications, except for metformin which will be continued at the prescribed dose (unless contraindicated). Insulin Degludec (U-100) will be given once daily at the same time for 26 weeks. The dose will be titrated up to the fasting blood glucose target of 70 to 100 mg/dL, with no maximum dose.
    Other Names:
  • Tresiba FlexTouch
  • Drug: Insulin Aspart
    Participants in the basal-bolus insulin study arm will discontinue all other diabetes medications, except for metformin which will be continued at the prescribed dose (unless contraindicated). Insulin aspart will be taken before meals with a titration schedule and dose adjustment protocol to target pre-meal blood glucose level of 70 to 100 mg/dL.
    Other Names:
  • NovoLog
  • Outcome Measures

    Primary Outcome Measures

    1. Change in Hemoglobin A1c (HbA1c) [Baseline, Week 26]

      HbA1c will be compared between study groups. HbA1c measures the average percentage of blood sugar over the past 2 to 3 months and HbA1c can reduce with management of diabetes through diet, exercise, and medication. HbA1c levels below 5.7% are considered normal. Persons with values between 5.7% and 6.4% are considered at high risk of developing diabetes while those with values of 6.5% and above are diagnosed with diabetes. Persons with diabetes aim to get their HbA1c in the range of 7.0 to 7.5% or lower, with below 7.0% being preferable.

    Secondary Outcome Measures

    1. Change in fasting blood glucose [Week1, Week 12, Week 26]

      Mean fasting blood glucose will be compared between study arms. Participants will perform an 8-point, self-monitored blood glucose (SMBG) check by testing their blood sugar at 8 different time points. The measurement taken before breakfast is used to assess fasting blood glucose. For people without diabetes, fasting blood glucose is typically between 70-100 mg/dL while fasting blood glucose for those with diabetes is in the range of 70-130 mg/dL.

    2. Change in daily blood glucose [Week1, Week 12, Week 26]

      Mean daily blood glucose will be compared between study arms. Participants will perform an 8-point, self-monitored blood glucose (SMBG) check by testing their blood sugar at 8 different time points. Blood glucose levels vary depending on when and what food has been consumed. A blood glucose level taken regardless of timing of meals of greater than 200 mg/dL often indicates diabetes. Blood glucose decreases with improved diabetes management.

    3. Participants with HbA1c <7.0% and hypoglycemia [Week 26]

      Percent of study participants experiencing HbA1c <7.0% and hypoglycemia will be compared between groups. Persons with diabetes aim to get their HbA1c in the range of 7.0 to 7.5% or lower, with below 7.0% being preferable. Hypoglycemia is defined as a blood glucose level of < 70 mg/dL.

    4. Participants with HbA1c <7.0% and no weight gain and no hypoglycemia [Week 26]

      Percent of study participants reaching A1c < 7% without weight gain and no hypoglycemia will be compared between groups. Weight control is typically important in persons with type 2 diabetes and basal-bolus insulin is associated with weight gain. Persons with diabetes aim to get their HbA1c in the range of 7.0 to 7.5% or lower, with below 7.0% being preferable. Hypoglycemia is defined as a blood glucose level of < 70 mg/dL.

    5. Participants with HbA1c <7.5% and no weight gain and no hypoglycemia [Week 26]

      Percent of study participants reaching A1c < 7.5% without weight gain and no hypoglycemia will be compared between groups. Weight control is typically important in persons with type 2 diabetes and basal-bolus insulin is associated with weight gain. Persons with diabetes aim to get their HbA1c in the range of 7.0 to 7.5% or lower, with below 7.0% being preferable. Hypoglycemia is defined as a blood glucose level of < 70 mg/dL.

    6. Participants with HbA1c >10% achieving HbA1c <7.5% [Baseline, Week 26]

      Percent of study participants with baseline HbA1c >10% reaching A1c < 7.5% will be compared between study groups. HbA1c measures the average percentage of blood sugar over the past 2 to 3 months and HbA1c can reduce with management of diabetes through diet, exercise, and medication. HbA1c levels below 5.7% are considered normal. Persons with values between 5.7% and 6.4% are considered at high risk of developing diabetes while those with values of 6.5% and above are diagnosed with diabetes. Persons with diabetes aim to get their HbA1c in the range of 7.0 to 7.5% or lower, with below 7.0% being preferable.

    7. Participants with HbA1c >10% achieving HbA1c <8.0% [Baseline, Week 26]

      Percent of study participants with baseline HbA1c >10% reaching A1c < 8.0% will be compared between study groups. HbA1c measures the average percentage of blood sugar over the past 2 to 3 months and HbA1c can reduce with management of diabetes through diet, exercise, and medication. HbA1c levels below 5.7% are considered normal. Persons with values between 5.7% and 6.4% are considered at high risk of developing diabetes while those with values of 6.5% and above are diagnosed with diabetes. Persons with diabetes aim to get their HbA1c in the range of 7.0 to 7.5% or lower, with below 7.0% being preferable.

    8. Participants with HbA1c >11% achieving HbA1c <7.5% [Baseline, Week 26]

      Percent of study participants with baseline HbA1c >11% reaching A1c < 7.5% will be compared between study groups. HbA1c measures the average percentage of blood sugar over the past 2 to 3 months and HbA1c can reduce with management of diabetes through diet, exercise, and medication. HbA1c levels below 5.7% are considered normal. Persons with values between 5.7% and 6.4% are considered at high risk of developing diabetes while those with values of 6.5% and above are diagnosed with diabetes. Persons with diabetes aim to get their HbA1c in the range of 7.0 to 7.5% or lower, with below 7.0% being preferable.

    9. Participants with HbA1c >11% achieving HbA1c <8.0% [Baseline, Week 26]

      Percent of study participants with baseline HbA1c >11% reaching A1c < 8.0% will be compared between study groups. HbA1c measures the average percentage of blood sugar over the past 2 to 3 months and HbA1c can reduce with management of diabetes through diet, exercise, and medication. HbA1c levels below 5.7% are considered normal. Persons with values between 5.7% and 6.4% are considered at high risk of developing diabetes while those with values of 6.5% and above are diagnosed with diabetes. Persons with diabetes aim to get their HbA1c in the range of 7.0 to 7.5% or lower, with below 7.0% being preferable.

    10. Participants with HbA1c <7.0% and no weight gain [Week 26]

      Percent of study participants reaching A1c < 7% without weight gain will be compared between groups.

    11. Participants with HbA1c <7.0% and no hypoglycemia [Week 12]

      Percent of study participants reaching A1c < 7% without hypoglycemia will be compared between groups. Hypoglycemia is defined as a blood glucose level of < 70 mg/dL.

    12. Documented symptomatic hypoglycemic events [Baseline through Week 26]

      Documented symptomatic hypoglycemia is defined as an event with typical symptoms of hypoglycemia accompanied by SMBG <70 mg/dL or continuous glucose monitoring (CGM) < 54 mg/dL that occurs at any time of the day. Incidence of documented hypoglycemic events will be compared between study groups.

    13. Asymptomatic hypoglycemic events [Baseline through Week 26]

      Asymptomatic hypoglycemia is defined as no typical symptoms reported by the study participant but detected by SMBG <70 mg/dL or continuous glucose monitoring (CGM) < 54 mg/dL. Incidence of asymptomatic hypoglycemic events will be compared between study groups.

    14. Severe hypoglycemic events [Baseline through Week 26]

      Severe hypoglycemia is defined as severe cognitive impairment requiring assistance from another person. Incidence of severe hypoglycemic events will be compared between study groups.

    15. Nocturnal symptomatic hypoglycemic events [Baseline through Week 26]

      Nocturnal symptomatic hypoglycemia is defined as an event with typical symptoms of hypoglycemia accompanied by SMBG <70 mg/dL or continuous glucose monitoring (CGM) < 54 mg/dL that occurs between midnight and 5:59 am. Incidence of nocturnal symptomatic hypoglycemic events will be compared between study groups.

    16. Nocturnal asymptomatic hypoglycemic events [Baseline through Week 26]

      Nocturnal asymptomatic hypoglycemia is defined as SMBG <70 mg/dL or continuous glucose monitoring (CGM) < 54 mg/dL between midnight and 5:59 am. Incidence of nocturnal asymptomatic hypoglycemic events will be compared between study groups.

    17. Percentage of time with interstitial glucose <70 mg/dL [Baseline through Week 26]

      Percentage of time with a interstitial glucose level below 70 mg/dL as obtained by CGM will be compared between study groups.

    18. Percentage of time with interstitial glucose <54 mg/dL [Baseline through Week 26]

      Percentage of time with a interstitial glucose level below <54 mg/dL as obtained by CGM will be compared between study groups.

    19. Percentage of time with interstitial glucose between 70 and 180 mg/dL [Baseline through Week 26]

      Percentage of time with interstitial glucose in the range of 70-180 mg/dL as measured by CGM will be compared between study groups.

    20. Change in glycemic variability [Week1, Week 12, Week 26]

      Glycemic variability will be assessed with continuous glucose monitoring (CGM). The rate of hypoglycemic events will be compared between treatment groups.

    21. Change in Diabetes Treatment Satisfaction Questionnaire - Status (DTSQs) Score [Baseline, Week 24]

      Treatment satisfaction will be assessed with the DTSQs. The DTSQs contains eight items scored on a seven-point scale where 0 = very dissatisfied and 6 = very satisfied. The satisfaction score is obtained by summing responses to yield a total score between 0 to 48. Higher scores indicate higher satisfaction with diabetes treatment.

    22. Diabetes Treatment Satisfaction Questionnaire - Change (DTSQc) Score [Week 26]

      Satisfaction with the study treatment will be assessed with items 1, 7, and 8 the DTSQc. Items are rated on a scale of -3 (much less satisfied compared to prior treatment) to 3 (much more satisfied compared to prior treatment). Total scores for these three items range from -9 to 9 with higher scores indicating greater satisfaction with the study treatment compared to their prior treatment.

    23. Change in Treatment-Related Impact Measures for Diabetes (TRIM-D) survey Score [Baseline, Week 12, Week 26]

      Satisfaction with the study treatment will be assessed with the TRIM-D survey. TRIM-D includes 28 items that are scored on a scale from 1 to 5. Total scores are transformed to a scale of 0 to 100 where higher scores indicate increased satisfaction.

    24. Number of emergency room visits [Baseline through Week 26]

      The number of emergency room visits occurring during the treatment period will be compared between study groups.

    25. Number of hospital readmissions [Baseline through Week 26]

      The number of hospital readmissions occurring during the treatment period will be compared between study groups.

    26. Change in total insulin dose [Baseline, Week 26]

      The total insulin dose measured in units per day will be compared between study groups.

    Eligibility Criteria

    Criteria

    Ages Eligible for Study:
    18 Years to 80 Years
    Sexes Eligible for Study:
    All
    Accepts Healthy Volunteers:
    No
    Inclusion Criteria:
    • Type 2 diabetes, diagnosed for ≥ 6 months

    • HBA1c ≥ 9% - 15%

    • Previously treated with oral antidiabetic agents, including metformin, sulfonylurea, repaglinide/nateglinide, pioglitazone, dipeptidyl peptidase-4 (DPP4), inhibitors, SGLT2 inhibitors, (monotherapy + basal insulin) or in combination therapy (2-3 agents), and/or on basal insulin (neutral protamine hagedorn (NPH), detemir or glargine U100) at a total daily dose (TDD) 20-50 units (stable doses of metformin and basal insulin for at least 90 days, defined as up to ±10% variability)

    • Body mass index (BMI) ≤ 45 Kg/m2

    Exclusion Criteria:
    • Subjects with type 1 diabetes or latent autoimmune diabetes of adults (LADA) (positive glutamic acid decarboxylase (GAD-65) antibody and/or ketones)

    • Subjects with a BG > 400 mg/dL during the screening visit and laboratory evidence of diabetic ketoacidosis

    • Previous treatment with glucagon-like peptide-1 (GLP-1) agonists (during prior 3 months)

    • Previous treatment with basal-bolus insulin (within prior 3 months)

    • Recurrent severe hypoglycemia or known hypoglycemia unawareness.

    • Personal or family history of medullary thyroid cancer or multiple endocrine neoplasia 2

    • Patients with acute or chronic pancreatitis, pancreatic cancer

    • Patients with clinically significant hepatic disease (cirrhosis, jaundice, end-stage liver disease) or significantly impaired renal function (GFR < 30 ml/min).

    • Treatment with oral or injectable corticosteroid (equivalent or higher than prednisone 5 mg/day), parenteral nutrition and immunosuppressive treatment.

    • Mental condition rendering the subject unable to understand the nature, scope, and possible consequences of the study

    • Hypersensitivity to study drugs

    • Participating in another investigational drug trial

    • The receipt of any investigational drug (within 3 months) prior to this trial.

    • Previously randomized in this trial

    • Heart Failure New York Heart Association (NYHA) class 4 or uncontrolled hypertension (blood pressure > 180/110 mmHg)

    • Female subjects who are pregnant or breast-feeding at time of enrollment into the study

    • Females of childbearing potential who are not using adequate contraceptive methods (as required by local law or practice)

    • Known or suspected allergy to trial medications (degludec, liraglutide, aspart), excipients, or related products.

    • Subjects could be excluded based on PI's discretion

    • Unable to comply with trial protocol, and/or at investigator discretion

    • Patients receiving treatment for active diabetic retinopathy or with proliferative retinopathy

    Contacts and Locations

    Locations

    Site City State Country Postal Code
    1 Grady Health System Atlanta Georgia United States 30303
    2 Emory Clinic Atlanta Georgia United States 30322

    Sponsors and Collaborators

    • Emory University
    • Novo Nordisk A/S

    Investigators

    • Principal Investigator: Rodolfo Galindo, MD, Emory University

    Study Documents (Full-Text)

    None provided.

    More Information

    Publications

    None provided.
    Responsible Party:
    Rodolfo Galindo, Assistant Professor, Emory University
    ClinicalTrials.gov Identifier:
    NCT03737240
    Other Study ID Numbers:
    • IRB00104726
    First Posted:
    Nov 9, 2018
    Last Update Posted:
    Aug 5, 2022
    Last Verified:
    Aug 1, 2022
    Studies a U.S. FDA-regulated Drug Product:
    Yes
    Studies a U.S. FDA-regulated Device Product:
    No
    Keywords provided by Rodolfo Galindo, Assistant Professor, Emory University
    Additional relevant MeSH terms:

    Study Results

    No Results Posted as of Aug 5, 2022