When we think about what medications to use in diabetes, we assess medications with regard to 5 characteristics: efficacy, effect on weight, hypoglycemia risk, side effect, and cost. This trial is unusual in that it compares 2 popular medications head-to-head. The results showed that insulin degludec essentially has the same efficacy and significantly less hypoglycemia than insulin glargine U100. Ten to 15 years ago, insulin glargine U-100 was shown to have less hypoglycemia than insulin NPH.¹ Three years ago, insulin glargine U-300 was shown to have less hypoglycemia than insulin glargine U-100.² GLP-1 receptor agonists have about the same efficacy as basal insulin but with far less hypoglycemia and they help people achieve weight loss instead of weight gain. The new fixed ratio combination basal insulin/GLP-1 RA provides greater efficacy than either basal insulin or GLP-1 RAs, with no greater hypoglycemia than the basal insulin component and with mitigation of the weight gain that often occurs with basal insulin. It is also clear that insulin degludec has less hypoglycemia than insulin glargine U-100. How it compares to insulin glargine U-300 remains unknown. We now have many choices and increasing evidence with which to make intelligent choices for our patients. —Neil Skolnik, MD

1. Rosenstock J, Dailey G, Massi-Benedetti M, Fritsche A, Lin Z, Salzman A, et al. Reduced hypoglycemia risk with insulin glargine: a meta-analysis comparing insulin glargine with human NPH insulin in type 2 diabetes. Diabetes Care 2005;28:950–955.
2. Riddle M, Bolli GB, Ziemen M, et al. New insulin glargine 300 units/mL versus glargine 100 units/mL in people with type 2 diabetes using basal and mealtime insulin: Glucose control and hypoglycemia in a 6-month randomized controlled trial (EDITION 1). Diabetes Care. 2014;37(10):2755-2762. doi:10.2337/dc14-0991.