Does metformin have to be the first treatment for type 2 diabetes?

This study examined whether a combination of empagliflozin (Jardiance) and linagliptin (Tradjenta) was effective as a first-line treatment in patients with type 2 diabetes.

Patients with type 2 diabetes either do not make enough or are resistant to insulin, the hormone needed to break down the glucose (sugar) taken in from food. Type 2 diabetes may initially be treated with changes to diet and exercise, but it is a progressive disease, and eventually glucose-lowering medications are needed. Metformin (Glucophage) is generally the first treatment used, as it increases the body’s sensitivity to insulin. However, many patients experience gastrointestinal side effects with metformin and cannot tolerate the treatment.

Empagliflozin lowers blood glucose levels by increasing the amount of glucose removed from the body through urine. Empagliflozin can also decrease body weight and blood pressure. Linagliptin, lowers blood glucose levels by stimulating the release of insulin. Because these two medications decrease blood glucose levels in different ways, the combination of the two may be an effective first-line treatment for type 2 diabetes.

This study compared treatment with a combination of empagliflozin and linagliptin to each drug alone. 677 patients were randomly assigned to one of five treatment groups for 52 weeks.

• Group 1: empagliflozin (10 mg) and linagliptin (5 mg)
• Group 2: empagliflozin (25 mg) and linagliptin (5 mg)
• Group 3: empagliflozin (10 mg)
• Group 4: empagliflozin (25 mg)
• Group 5: linagliptin (5 mg)

HbA1c (average blood glucose levels over 3 months) levels at week 24 were compared to those at the start of the study.

The combination of empagliflozin (10 mg) plus linagliptin (5 mg) led to the greatest decrease in HbA1c (1.24%). This decrease was significantly greater than those seen in patients receiving only one of the medications (ranging from 0.67% decrease to 0.95% decrease). Empagliflozin (10 mg) plus linagliptin (5 mg) also led to the highest number of patients (62.3%) who achieved HbA1c levels less than 7%. In comparison, 32.3%­ to 41.5% of patients receiving only one medication achieved HbA1c levels less than 7%.

Rates of adverse (negative) events were similar across the treatment groups. There were no confirmed cases of hypoglycemia (dangerously low blood glucose levels).

This study concluded that the combination of empagliflozin and linagliptin was an effective first-line treatment in patients with type 2 diabetes.