Tirzepatide vs Insulin Lispro Added to Basal Insulin in Type 2 Diabetes The SURPASS-6 Randomized Clinical Trial

IMPORTANCE Tirzepatide is a glucose-dependent insulinotropic polypeptide and glucagon-like peptide-1 receptor agonist used for the treatment of type 2 diabetes. Efficacy and safety of adding tirzepatide vs prandial insulin to treatment in patients with inadequate glycemic control with basal insulin have not been described. OBJECTIVE To assess the efficacy and safety of tirzepatide vs insulin lispro as an adjunctive therapy to insulin glargine. DESIGN, SETTING, AND PARTICIPANTS This open-label, phase 3b clinical trial was conducted at 135 sites in 15 countries (participants enrolled from October 19, 2020, to November 1, 2022) in 1428 adults with type 2 diabetes taking basal insulin. INTERVENTIONS Participants were randomized (in a 1:1:1:3 ratio) to receive once-weekly subcutaneous injections of tirzepatide (5mg [n = 243], 10mg [n = 238], or 15 mg [n = 236]) or prandial thrice-daily insulin lispro (n = 708). MAIN OUTCOMES AND MEASURES Outcomes included noninferiority of tirzepatide (pooled cohort) vs insulin lispro, both in addition to insulin glargine, in HbA(1c) change from baseline at week 52 (noninferiority margin, 0.3%). Key secondary end points included change in body weight and percentage of participants achieving hemoglobin A(1c) (HbA(1c)) target of less than 7.0%. RESULTS Among 1428 randomized participants (824 [57.7%] women; mean [SD] age, 58.8 [9.7] years; mean [SD] HbA(1c), 8.8% [1.0%]), 1304 (91.3%) completed the trial. At week 52, estimated mean change from baseline in HbA(1c) with tirzepatide (pooled cohort) was -2.1% vs -1.1% with insulin lispro, resulting in mean HbA(1c) levels of 6.7% vs 7.7%(estimated treatment difference, -0.98%[95% CI, -1.17% to -0.79%]; P <.001); results met noninferiority criteria and statistical superiority was achieved. Estimated mean change from baseline in body weight was -9.0 kg with tirzepatide and 3.2 kg with insulin lispro (estimated treatment difference, -12.2 kg [95% CI, -13.4 to -10.9]). The percentage of participants reaching HbA(1c) less than 7.0% was 68%(483 of 716) with tirzepatide and 36%(256 of 708) with insulin lispro (odds ratio, 4.2 [95% CI, 3.2-5.5]). The most common adverse events with tirzepatide were mild to moderate gastrointestinal symptoms (nausea: 14%-26%; diarrhea: 11%-15%; vomiting: 5%-13%). Hypoglycemia event rates (blood glucose level <54mg/dL or severe hypoglycemia) were 0.4 events per patient-year with tirzepatide (pooled) and 4.4 events per patient-year with insulin lispro. CONCLUSIONS AND RELEVANCE In people with inadequately controlled type 2 diabetes treated with basal insulin, weekly tirzepatide compared with prandial insulin as an additional treatment with insulin glargine demonstrated reductions in HbA(1c) and body weight with less hypoglycemia.