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We are seeing type 2 diabetes more frequently in paediatrics in association with the increase in obesity. Insulin is sometimes used as the final addition to management in an attempt to control blood sugar when all other measures have failed. The Archivist was intrigued to read this adult study (all participants were aged over 18 years and had type 2 diabetes), where they used insulin efsitora alpha, a new insulin analogue that is long-acting and only needs to be given once a week for basal control of blood sugar. Once-a-week injection is certainly an attractive option. Rosenstock et al (N Engl J Med 2025;393:325–35. DOI: 10.1056/NEJMe2508147) conducted this open-label, treat-to-target, phase 3, non-inferiority trial involving 795 adults with type 2 diabetes who had not previously received insulin therapy. The study was conducted over a year, where the participants were randomly assigned in a 1:1 ratio; 397 received efsitora once a week and 398 received glargine once a day, both at U100 units. Dose adjustments were made every 4 weeks, as needed, at fixed doses of 150, 250 and 400 U to achieve fasting blood glucose levels of 80–130 mg/dL (4.44–7.21 mmol/L). Non-inferiority was shown. The mean glycated haemoglobin level decreased from 8.20% at baseline to 7.05% at week 52 with efsitora (least-squares mean change, −1.19 percentage points) and from 8.28% to 7.08% with glargine (least-squares mean change, −1.16 percentage points); the estimated between-group difference of −0.03 percentage points (95% CI, −0.18 to 0.12) confirmed the non-inferiority of efsitora to glargine. They had predefined a non-inferiority margin of 0.4 percentage points. The Archivist noted that they did not monitor continuous blood sugar, which really should be part of any diabetes trial and that ‘time in range’ should be an outcome. This study is part of the once-a-week (QW) insulin therapy (QWINT) phase 3 programme. There are five studies in this programme and now all have been published. Interestingly, this study used the gatekeeper approach to reduce type 1 error (see other Archivist for September) in their analysis of their primary endpoints, and they made no multiplicity adjustments for evaluating other secondary and exploratory endpoints or for safety assessments. The other interesting feature of this study was that they stratified randomisation for those individuals who were taking the glucagon-like peptide-1 (GLP-1) receptor agonists (7.9%), and 93.5% were taking Metformin at baseline. The mean body mass index was 31.9 for the entire cohort. An editorial by Inglefinger et al (N Engl J Med 2025; 393:401–402. DOI: 10.1056/NEJMe2508147) discusses the QWINT studies, type 2 diabetes management, the impact of GLP-1 receptor agonists and other diabetes programmes such as the ONWARDS studies, which are examining the role of icodec insulin, another long-acting insulin. It will be interesting to see the development and results of the paediatric studies, as a once-a-week injection will have important practical and adherence implications for children.