Nateglinide improves glycaemic control when added to metformin monotherapy: results of a randomized trial with type 2 diabetes patients

Aims/hypothesis: This study evaluated the addition of nateglinide, a d ‐phenylalanine derivative that restores early phase insulin release, to metformin in type 2 diabetes patients stabilized on high‐dose metformin. Methods: This multicentre, double‐blind, parallel group trial included 467 metformin‐treated patients with glycosylated haemoglobin (HbA 1c ) between 6.8% and 11%. Patients were randomized to add nateglinide 60 mg, 120 mg or placebo before three meals to metformin 1000 mg b.i.d. for 24 weeks. Results: HbA 1c was significantly reduced with nateglinide 60 mg and 120 mg plus metformin compared with metformin control (−0.36%, p = 0.003; −0.59%, p < 0.001 respectively). Greater benefits occurred if patients had elevated HbA 1c at baseline (−1.38% with nateglinide 120 mg in patients with HbA 1c > 9.5%). A modest fasting plasma glucose reduction was observed. Most symptoms suggestive of hypoglycaemia occurred in patients with low HbA 1c levels (≤ 8%) at baseline, although no confirmed cases of hypoglycaemia occurred with nateglinide 60 mg in this patient group. Events suggestive of hypoglycaemia were confirmed in 1.1% of cases (plasma glucose ≤ 3.3 mmol/l). Weight gain over 24 weeks was 0.9 kg with nateglinide 120 mg vs. metformin alone, and plasma lipids remained unchanged. Conclusions/interpretation: In patients stabilized on high‐dose metformin, the addition of nateglinide improved glycaemic control. The combination of these agents was well tolerated and both doses of nateglinide proved effective. The efficacy of nateglinide 60 mg and the low rate of hypoglycaemia observed at this dose make it suitable for patients close to their therapeutic target on metformin monotherapy.