Strengths and Limitations
Strengths of this project include the large sample size, its setting in a large VA medical center, and the evaluation of multiple outcomes beyond HbA1c for assessment of glycemic control (ie, mean blood glucose, insulin titration, and dose adjustment of other glucose-lowering agents).
Limitations of this study include the retrospective chart review used for data collection, limited accuracy of objective data due to the COVID-19 pandemic, and inconsistencies with documentation in patients’ electronic health records. As a protective measure in the height of the pandemic between March 2021 and November 2021, the VA promoted using telephone and virtual-visit clinics to minimize exposure for patients with nonurgent follow-up needs. Patient hesitance to present to the clinic in person due to COVID-19 was also a significant factor in obtaining objective follow-up data. As a result, less accurate and timely baseline and postconversion weight and HbA1c data resulted, leading to our decision to extend the timeframe evaluated postconversion to 3 to 12 months. We also noted inconsistencies with documentation in CPRS. Unless veterans were closely followed by clinical pharmacist practitioners or endocrine consultation service clinicians, it was more difficult to follow and document trends of insulin titration to assess the impact of semaglutide conversion. The number of AEs, including hypoglycemia and GI intolerance, were also not consistently documented within the CPRS, and the frequency of AEs may be underestimated.
Another possible limitation regarding the interpretation of the results includes the portion of patients titrated up to semaglutide 1 mg weekly. As the focal point of this project was to review changes in glycemic control in the conversion to semaglutide 0.5 mg, this population of patients converted to 1 mg could potentially overestimate the HbA1c and weight changes described, as it is consistent with the SUSTAIN trials that show more robust decreases in those parameters described earlier.
Conclusions
A subset of patients with T2DM converted from liraglutide to semaglutide experienced significant changes in glycemic control and body weight. Significant differences were noted for a decreased HbA1c, decreased mean blood glucose, and weight loss. A fair portion of patients’ antihyperglycemic regimens required no changes on conversion to semaglutide. Although the semaglutide discontinuation rate neared 10%, AEs that may have contributed to this discontinuation rate included hypoglycemia and GI intolerance. Clinician education resulted in a substantial number of patients undergoing teleretinal imaging and further conversion to semaglutide; however, due to the low conversion response rate, a more effective method of educating clinicians is warranted. Although the semaglutide cost savings initiative at MEDVAMC resulted in significant savings, a full cost-effective analysis is needed to assess more comprehensive institution savings.