Treatment response between Asian and non-Asian patients with type 2 diabetes

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Treatment response between Asian and non-Asian patients with type 2 diabetes: is there any similarity or difference?

Diabetes is a growing global emergency, but nowhere is the crisis more urgent than in Asia. The International Diabetes Federation’s 2017 Diabetes Atlas reports over 600 million Asians live with type 2 diabetes or are prediabetic—more than any other region. What makes this even more striking? Asians develop diabetes at lower body weights than non-Asians: someone with a “normal” body mass index (BMI, 18.5–23.9) in Asia has the same risk as an overweight person (BMI 25–29.9) in Europe or the U.S. This is partly due to differences in beta-cell function (the pancreas cells that make insulin) and genetics. But does ethnicity change how patients respond to diabetes treatments? A 2019 analysis by Xiao-Ling Cai and Li-Nong Ji from the Department of Endocrinology and Metabolism at Peking University People’s Hospital in Beijing explores this critical question, comparing treatment outcomes across ethnicities to help tailor better care.

Oral Anti-Diabetes Drugs

Oral medications are the first line of treatment for most people with type 2 diabetes. Here’s how Asian and non-Asian patients respond to common options:

Alpha Glucosidase Inhibitors (AGIs)

AGIs slow carbohydrate digestion, helping to reduce post-meal blood sugar spikes. A 2018 meta-analysis of 67 trials (published in J Diabetes Investigation) found no significant differences in how Asian and Caucasian patients responded: both groups saw similar drops in HbA1c (a 3-month average of blood sugar levels) and weight. The risk of hypoglycemia (low blood sugar) was also comparable.

Dipeptidyl Peptidase-4 (DPP-4) Inhibitors

These drugs boost insulin production when blood sugar is high and reduce glucagon (a hormone that raises blood sugar). A 2013 systematic review in Diabetologia found Asians had a slightly larger HbA1c reduction (0.26% more) than non-Asians, but weight changes were similar. However, a smaller study of patients adding DPP-4 inhibitors to metformin and sulfonylureas (published in Int J Endocrinol) found no difference in glycemic improvement between ethnicities.

Sodium-Glucose Cotransporter 2 (SGLT2) Inhibitors

SGLT2 inhibitors help the kidneys remove excess sugar from the blood. A 2018 meta-analysis in J Diabetes Investigation found Asian and non-Asian patients had similar HbA1c and weight reductions. However, Asians saw more favorable cholesterol changes: a 0.14 mmol/L drop in triglycerides and a 0.09 mmol/L increase in high-density lipoprotein (HDL, or “good” cholesterol)—both statistically significant.

Metformin, Sulfonylureas, and Thiazolidinediones

While no direct comparisons exist for these widely used drugs, trial data suggests similar responses. A 2013 open-label study of Chinese patients (published in PLoS One) found metformin lowered HbA1c by ~1.8% in normal-weight, overweight, and obese patients—matching results from the ADOPT trial (a key study of Caucasian patients). A double-blind trial of Chinese patients using Xiaoke Pill (a combination of Chinese herbs and glibenclamide) or glibenclamide alone saw similar HbA1c drops (~0.7%) at 48 weeks—consistent with ADOPT results in Caucasians. For thiazolidinediones (e.g., pioglitazone), a Japanese study found a 0.67% HbA1c reduction with metformin plus pioglitazone—similar to the 0.80% drop reported in Caucasians from a 2011 meta-analysis.

GLP-1 Receptor Agonists (Injectable Therapies)

Glucagon-like peptide-1 (GLP-1) receptor agonists are injectable drugs that mimic a gut hormone to lower blood sugar and reduce appetite. A 2014 meta-analysis of 15 trials (published in Diabetes Obes Metab) found Asian patients had a larger HbA1c reduction (0.32% more) than non-Asians. However, Asians faced a higher risk of hypoglycemia: 2.8 times more likely than non-Asians, who were 1.5 times more likely than placebo. Weight changes were similar between groups.

Insulin Treatment

Insulin is a cornerstone of diabetes care for patients who can’t control blood sugar with oral drugs. Studies show the most consistent ethnic differences here:

  • A 2013 post-hoc analysis of the DURABLE trial (over 2,000 patients) found Asian patients on twice-daily insulin lispro mix 75/25 had a smaller HbA1c drop (1.46% vs. 1.84% in Caucasians) but gained less weight (2.6 kg vs. 3.6 kg) and had fewer hypoglycemia events (15 vs. 23 per year).
  • A 2016 post-hoc analysis of the PARADIGM study found East Asians on insulin lispro mix 25 had similar HbA1c reductions (2.03% vs. 2.07% in non-Asians) but a much lower hypoglycemia rate (69.8% vs. 94.1%).
  • A 2018 pooled analysis of 16 trials (published in Diabetes Res Clin Pract) found Asian patients starting long-acting insulin glargine had a smaller HbA1c drop (1.3% vs. 1.6%) and less weight gain (1.3 kg vs. 1.9 kg) than non-Asians. Fasting blood sugar reductions and hypoglycemia rates were similar.

Limitations of the Research

While these findings are valuable, most studies are “post-hoc”—meaning they re-analyzed existing data instead of designing trials specifically to test ethnicity. This means factors like diet, exercise habits, access to healthcare, and treatment adherence weren’t fully controlled. These cultural and social differences could affect how patients respond to treatment, so results should be interpreted with caution.

What This Means for Care

Asian patients with type 2 diabetes have unique characteristics: lower BMIs, younger ages, and earlier beta-cell decline. But their treatment responses are a mix of similarities and differences:

  • Similar responses: Alpha glucosidase inhibitors, SGLT2 inhibitors, metformin, sulfonylureas, and thiazolidinediones work similarly across ethnicities.
  • Differences: GLP-1 receptor agonists may lower HbA1c more in Asians but carry a higher hypoglycemia risk. Insulin often leads to smaller HbA1c drops and less weight gain in Asians, with lower hypoglycemia rates in some regimens.

Understanding these patterns can help doctors create more personalized treatment plans for Asian patients—ensuring they get effective care while minimizing risks like low blood sugar or weight gain.

References

  1. International Diabetes Federation. Diabetes Atlas. 8th ed. 2017; International Diabetes Federation, Belgium: Available from: https://www.idf.org/e-library/epidemiology-research/diabetes-atlas/134-idf-diabetes-atlas-8th-edition.html. Accessed August 1, 2018.
  2. Yang W, Lu J, Weng J, Jia W, Ji L, Xiao J, et al. Prevalence of diabetes among men and women in China. N Engl J Med 2010;362:1090–1101. doi.org/10.1056/NEJMoa0908292.
  3. Xu Y, Wang L, He J, Bi Y, Li M, Wang T, et al. Prevalence and control of diabetes in Chinese adults. JAMA 2013;310:948–959. doi.org/10.1001/jama.2013.168118.
  4. Ma RC, Chan JC. Type 2 diabetes in East Asians: similarities and differences with populations in Europe and the United States. Ann N Y Acad Sci 2013;1281:64–91. doi.org/10.1111/nyas.12098.
  5. Tuomi T, Santoro N, Caprio S, Cai M, Weng J, Groop L. The many faces of diabetes: a disease with increasing heterogeneity. Lancet 2014;383:1084–1094. doi.org/10.1016/S0140-6736(13)62219-9.
  6. Moller JB, Dalla Man C, Overgaard RV, Ingwersen SH, Tornøe CW, Pedersen M, et al. Ethnic differences in insulin sensitivity, beta-cell function, and hepatic extraction between Japanese and Caucasians: a minimal model analysis. J Clin Endocrinol Metab 2014;99:4273–4280. doi.org/10.1210/jc.2014-1724.
  7. Yang W, Weng J. Early therapy for type 2 diabetes in China. Lancet Diabetes Endocrinol 2014;2:992–1002. doi.org/10.1016/S2213-8587(14)70136-6.
  8. Cho YS, Lee JY, Park KS, Nho CW. Genetics of type 2 diabetes in East Asian populations. Curr Diabetes Rep 2012;12:686–696. doi.org/10.1007/s11892-012-0326-z.
  9. Ramachandran A, Ma RC, Snehalatha C. Diabetes in Asia. Lancet 2010;375:408–418. doi.org/10.1016/S0140-6736(09)60937-5.
  10. Gao X, Cai X, Yang W, Chen Y, Han X, Ji L, et al. Meta-analysis and critical review on the efficacy and safety of alpha-glucosidase inhibitors in Asian and non-Asian populations. J Diabetes Investigation 2018;9:321–331. doi.org/10.1111/jdi.12711.
  11. Cai X, Han X, Luo Y, Ji L. Comparisons of the efficacy of alpha glucosidase inhibitors on type 2 diabetes patients between Asian and Caucasian. PLoS One 2013;8:e79421. doi.org/10.1371/journal.pone.0079421.
  12. Kim YG, Hahn S, Oh TJ, Kwak SH, Park KS, Cho YM. Differences in the glucose-lowering efficacy of dipeptidyl peptidase-4 inhibitors between Asians and non-Asians: a systematic review and meta-analysis. Diabetologia 2013;56:696–708. doi.org/10.1007/s00125-012-2827-3.
  13. Cai X, Han X, Luo Y, Ji L. Efficacy of dipeptidyl-peptidase-4 inhibitors and impact on beta-cell function in Asian and Caucasian type 2 diabetes mellitus patients: a meta-analysis. J Diabetes 2015;7:347–359. doi.org/10.1111/1753-0407.12196.
  14. Fujita K, Kaneko M, Narukawa M. Factors related to the glucose-lowering efficacy of dipeptidyl peptidase-4 inhibitors: a systematic review and meta-analysis focusing on ethnicity and study regions. Clin Drug Investig 2017;37:219–232. doi.org/10.1007/s40261-016-0478-8.
  15. Zhang X, Brooks B, Molyneaux L, Landy E, Banatwalla R, Wu T, et al. Dipeptidyl peptidase-4 inhibitors as a third-line oral antihyperglycaemic agent in patients with type 2 diabetes mellitus: the impact of ethnicity. Int J Endocrinol 2014;2014:354040. doi.org/10.1155/2014/354040.
  16. Cai X, Gao X, Yang W, Chen Y, Zhang S, Zhou L, et al. No disparity of the efficacy and all-cause mortality between Asian and non-Asian type 2 diabetes patients with sodium-glucose cotransporter 2 inhibitors treatment: a meta-analysis. J Diabetes Investig 2018;9:850–861. doi.org/10.1111/jdi.12760.
  17. Ji L, Li H, Guo X, Li Y, Hu R, Zhu Z. Impact of baseline BMI on glycemic control and weight change with metformin monotherapy in Chinese type 2 diabetes patients: phase IV open-label trial. PLoS One 2013;8:e57222. doi.org/10.1371/journal.pone.0057222.
  18. Kahn SE, Haffner SM, Heise MA, Herman WH, Holman RR, Jones NP, et al. Glycemic durability of rosiglitazone, metformin, or glyburide monotherapy. N Engl J Med 2006;355:2427–2443. doi.org/10.1056/NEJMoa066224.
  19. Ji L, Tong X, Wang H, Tian H, Zhou H, Zhang L, et al. Efficacy and safety of traditional Chinese medicine for diabetes: a double-blind, randomised, controlled trial. PLoS One 2013;8:e56703. doi.org/10.1371/journal.pone.0056703.
  20. Kaku K. Efficacy and safety of therapy with metformin plus pioglitazone in the treatment of patients with type 2 diabetes: a double-blind, placebo-controlled, clinical trial. Curr Med Res Opin 2009;25:1111–1119. doi.org/10.1185/03007990902820816.
  21. Cai X, Chen Y, Zhao J, Shan ZY, Qiu MC, Li CJ, et al. Efficacy and safety of avandamet or uptitrated metformin treatment in patients with type 2 diabetes inadequately controlled with metformin alone: a multicenter, randomized, controlled trial. Chin Med J 2015;128:1279–1287. doi.org/10.4103/0366-6999.156735.
  22. McIntosh B, Cameron C, Singh SR, Yu C, Ahuja T, Welton NJ, et al. Second-line therapy in patients with type 2 diabetes inadequately controlled with metformin monotherapy: a systematic review and mixed-treatment comparison meta-analysis. Open Med 2011;5:e35–e48.
  23. Kim YG, Hahn S, Oh TJ, Park KS, Cho YM. Differences in the HbA1c-lowering efficacy of glucagon-like peptide-1 analogues between Asians and non-Asians: a systematic review and meta-analysis. Diabetes Obes Metab 2014;16:900–909. doi.org/10.1111/dom.12293.
  24. Davidson JA, Wolffenbuttel BH, Arakaki RF, Caballero AE, Jiang HH, Hardin DS. Impact of race/ethnicity on efficacy and safety of two starter insulin regimens in patients with type 2 diabetes: a posthoc analysis of the DURABLE trial. Ethn Dis 2013;23:393–400.
  25. Ji L, Min KW, Oliveira J, Lew T, Duan R. Comparison of efficacy and safety of two starting insulin regimens in non-Asian, Asian Indian, and East Asian patients with type 2 diabetes: a post hoc analysis of the PARADIGM study. Diabetes Metab Syndr Obes 2016;9:243–249. doi.org/10.2147/DMSO.S104752.
  26. Chan JCN, Bunnag P, Chan SP, Tan ITI, Tsai ST, Gao L, et al. Glycaemic responses in Asian and non-Asian people with type 2 diabetes initiating insulin glargine 100 units/mL: a patient-level pooled analysis of 16 randomised controlled trials. Diabetes Res Clin Pract 2018;135:199–205. doi.org/10.1016/j.diabres.2017.11.025.

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