Individualizing treatment choices for patients with type 2 diabetes according to patient preference

Abstract

Many patients with Type 2 diabetes will require additional glucose lowering treatment to achieve optimal glucose control. Ensuring treatment adherence is therefore crucial in order to reduce the long-term risks of complications. A study recently published in Nature Medicine, known as the TriMaster study is the first study to evaluate the effectiveness of allowing people with type 2 diabetes to choose their own second/third line medication to manage hyperglycaemia. This approach was thought to balance the potential efficacy with potential side effects profiles of the selected drugs. The study led by academics from the University of Exeter was a randomized double-blind, three-way cross over trial where patients received three different second- or third-line once-daily type 2 diabetes glucose-lowering drugs (pioglitazone 30 mg, sitagliptin 100 mg and canagliflozin 100 mg). As part of a prespecified secondary endpoint, patients' drug preference were examined after they had tried all three drugs. In total, 448 participants were treated with all three drugs which overall showed similar glucose lowering outcomes. In terms of preference, 115 patients (25%) preferred pioglitazone, 158 patients (35%) sitagliptin and 175 patients (38%) canagliflozin. The drug preferred by individual patients was associated with a lower HbA1c (mean: 4.6; 95% CI: 3.9, 5.3) mmol mol⁻¹ lower versus nonpreferred) and was associated with fewer side effects (mean: 0.50; 95% CI: 0.35, 0.64) fewer side effects versus nonpreferred). This study showed that allocating therapy based on patients individually preferred drugs, rather than allocating all patients the overall most preferred drug (canagliflozin), would result in more patients achieving the lowest HbA1c for them (70% versus 30%) and the fewest side effects (67% versus 50%). Given the comparable glucose lowering ability of different drugs, allowing patients to try suitable medications before they choose long-term therapy according to their treatment preference could be a practical alternative to individualised treatment strategy for type 2 diabetes that would facilitate long-term treatment compliance.