Network meta-analysis
HbA1c change
Type 2 diabetes (adults); background therapy: one or more non insulin glucose lowering drugs
weeks 36 to 64 (target week 52)Hypothetical (as if everyone stayed on treatment)Doses of a drug pooledMean difference
12
Randomized trials
13
Treatments
7,637
Participants
24
Trial arms
In plain language
Across 12 trials with 7,637 participants, 4 of 12 treatments had a clearly better result than placebo on HbA1c change, and for 8 the evidence could not tell them apart from placebo. The most favorable estimate was for Tirzepatide injection: mean difference -2.20 percentage points (95% credible interval -3.20 to -0.31).
Lower values favor the treatment. "Clearly" means the 95% credible interval excludes no difference. These are averages across trials; they do not say how any one person will respond. Not medical advice.
Network of trials
Each circle is a treatment; each line joins treatments that were randomized against each other in at least one trial.
Effects compared with Placebo
Mean difference in percentage points. Lower values favor the treatment.
| Treatment | Bayesian MD (95% CrI) | 95% prediction interval | Frequentist MD (95% CI) | Verdict |
|---|---|---|---|---|
| Tirzepatide injection TIRZ_SC | -2.20 (-3.20 to -0.31) | -3.43 to 0.01 | -2.53 (-2.90 to -2.15) | Better |
| Orforglipron tablet ORFO_PO | -2.00 (-2.85 to -0.48) | -3.22 to -0.14 | -2.15 (-2.38 to -1.92) | Better |
| Semaglutide injection SEMA_SC | -1.78 (-2.84 to -0.57) | -3.10 to -0.26 | -2.00 (-2.90 to -1.10) | Better |
| Insulin degludec INS_DEGLUDEC | -1.37 (-2.54 to 0.83) | -2.75 to 1.08 | -1.70 (-2.10 to -1.31) | Unclear |
| Semaglutide tablet SEMA_PO | -1.26 (-1.83 to -0.24) | -2.23 to 0.21 | -1.40 (-1.60 to -1.20) | Better |
| Dulaglutide injection DULA_SC | -1.15 (-1.87 to 0.24) | -2.20 to 0.61 | -1.38 (-1.69 to -1.07) | Unclear |
| Exenatide extended release injection EXENER_SC | -1.15 (-2.39 to 0.40) | -2.67 to 0.67 | -1.38 (-2.30 to -0.46) | Unclear |
| Canagliflozin CANAGLIFLOZIN | -1.07 (-2.34 to 0.47) | -2.57 to 0.73 | -1.30 (-2.21 to -0.39) | Unclear |
| Sitagliptin SITAGLIPTIN | -0.85 (-1.74 to 0.59) | -2.10 to 0.92 | -1.00 (-1.32 to -0.68) | Unclear |
| Insulin glargine INS_GLARGINE | -0.81 (-1.65 to 0.83) | -1.94 to 1.15 | -1.09 (-1.43 to -0.75) | Unclear |
| Exenatide injection EXEN_SC | -0.74 (-1.77 to 1.03) | -2.03 to 1.32 | -0.96 (-1.33 to -0.60) | Unclear |
| Albiglutide injection ALBI_SC | -0.69 (-1.73 to 1.22) | -1.94 to 1.48 | -0.97 (-1.34 to -0.60) | Unclear |
Ranking
How likely each treatment is to be among the best. Rankings ignore the size of differences and their certainty, so read them with the effects above.
League table
Every treatment against every other: mean difference of the row treatment versus the column treatment, posterior median and 95% credible interval. Green: row clearly better; red: row clearly worse.
| Row versus column | PLACEBO | TIRZ_SC | ORFO_PO | SEMA_SC | INS_DEGLUDEC | SEMA_PO | DULA_SC | EXENER_SC | CANAGLIFLOZIN | SITAGLIPTIN | INS_GLARGINE | EXEN_SC | ALBI_SC |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| PLACEBO | PLACEBO | 2.20 0.31 to 3.20 | 2.00 0.48 to 2.85 | 1.78 0.57 to 2.84 | 1.37 -0.83 to 2.54 | 1.26 0.24 to 1.83 | 1.15 -0.24 to 1.87 | 1.15 -0.40 to 2.39 | 1.07 -0.47 to 2.34 | 0.85 -0.59 to 1.74 | 0.81 -0.83 to 1.65 | 0.74 -1.03 to 1.77 | 0.69 -1.22 to 1.73 |
| TIRZ_SC | -2.20 -3.20 to -0.31 | TIRZ_SC | -0.24 -1.62 to 1.63 | -0.35 -1.95 to 1.71 | -0.83 -1.84 to 0.04 | -0.96 -2.03 to 0.68 | -1.06 -2.10 to 0.34 | -1.01 -2.70 to 1.18 | -1.08 -2.80 to 1.18 | -1.38 -2.74 to 0.49 | -1.40 -2.20 to -0.41 | -1.48 -2.83 to 0.16 | -1.52 -2.72 to -0.15 |
| ORFO_PO | -2.00 -2.85 to -0.48 | 0.24 -1.63 to 1.62 | ORFO_PO | -0.16 -1.62 to 1.57 | -0.60 -2.71 to 0.95 | -0.72 -1.58 to 0.29 | -0.82 -2.12 to 0.38 | -0.80 -2.50 to 1.12 | -0.88 -2.62 to 1.10 | -1.14 -2.39 to 0.22 | -1.15 -2.77 to 0.09 | -1.23 -2.80 to 0.24 | -1.27 -3.07 to 0.17 |
| SEMA_SC | -1.78 -2.84 to -0.57 | 0.35 -1.71 to 1.95 | 0.16 -1.57 to 1.62 | SEMA_SC | -0.49 -2.75 to 1.22 | -0.56 -1.98 to 0.74 | -0.67 -2.34 to 0.72 | -0.63 -1.58 to 0.23 | -0.71 -1.70 to 0.21 | -0.98 -2.69 to 0.56 | -1.03 -2.84 to 0.41 | -1.08 -3.05 to 0.53 | -1.16 -3.15 to 0.44 |
| INS_DEGLUDEC | -1.37 -2.54 to 0.83 | 0.83 -0.04 to 1.84 | 0.60 -0.95 to 2.71 | 0.49 -1.22 to 2.75 | INS_DEGLUDEC | -0.12 -1.38 to 1.79 | -0.23 -1.47 to 1.50 | -0.17 -1.98 to 2.30 | -0.25 -2.09 to 2.25 | -0.53 -2.07 to 1.57 | -0.56 -1.66 to 0.82 | -0.64 -2.13 to 1.30 | -0.69 -2.07 to 1.03 |
| SEMA_PO | -1.26 -1.83 to -0.24 | 0.96 -0.68 to 2.03 | 0.72 -0.29 to 1.58 | 0.56 -0.74 to 1.98 | 0.12 -1.79 to 1.38 | SEMA_PO | -0.10 -1.07 to 0.62 | -0.08 -1.61 to 1.54 | -0.16 -1.71 to 1.47 | -0.41 -1.38 to 0.47 | -0.43 -1.76 to 0.47 | -0.51 -1.92 to 0.60 | -0.56 -2.18 to 0.61 |
| DULA_SC | -1.15 -1.87 to 0.24 | 1.06 -0.34 to 2.10 | 0.82 -0.38 to 2.12 | 0.67 -0.72 to 2.34 | 0.23 -1.50 to 1.47 | 0.10 -0.62 to 1.07 | DULA_SC | 0.02 -1.55 to 1.90 | -0.05 -1.63 to 1.82 | -0.31 -1.48 to 1.04 | -0.33 -1.29 to 0.41 | -0.42 -1.34 to 0.52 | -0.46 -1.75 to 0.67 |
| EXENER_SC | -1.15 -2.39 to 0.40 | 1.01 -1.18 to 2.70 | 0.80 -1.12 to 2.50 | 0.63 -0.23 to 1.58 | 0.17 -2.30 to 1.98 | 0.08 -1.54 to 1.61 | -0.02 -1.90 to 1.55 | EXENER_SC | -0.07 -1.34 to 1.20 | -0.34 -2.21 to 1.41 | -0.38 -2.39 to 1.21 | -0.44 -2.59 to 1.32 | -0.51 -2.67 to 1.28 |
| CANAGLIFLOZIN | -1.07 -2.34 to 0.47 | 1.08 -1.18 to 2.80 | 0.88 -1.10 to 2.62 | 0.71 -0.21 to 1.70 | 0.25 -2.25 to 2.09 | 0.16 -1.47 to 1.71 | 0.05 -1.82 to 1.63 | 0.07 -1.20 to 1.34 | CANAGLIFLOZIN | -0.26 -2.14 to 1.43 | -0.30 -2.37 to 1.30 | -0.37 -2.49 to 1.45 | -0.43 -2.59 to 1.36 |
| SITAGLIPTIN | -0.85 -1.74 to 0.59 | 1.38 -0.49 to 2.74 | 1.14 -0.22 to 2.39 | 0.98 -0.56 to 2.69 | 0.53 -1.57 to 2.07 | 0.41 -0.47 to 1.38 | 0.31 -1.04 to 1.48 | 0.34 -1.41 to 2.21 | 0.26 -1.43 to 2.14 | SITAGLIPTIN | -0.03 -1.65 to 1.27 | -0.10 -1.83 to 1.40 | -0.15 -2.02 to 1.31 |
| INS_GLARGINE | -0.81 -1.65 to 0.83 | 1.40 0.41 to 2.20 | 1.15 -0.09 to 2.77 | 1.03 -0.41 to 2.84 | 0.56 -0.82 to 1.66 | 0.43 -0.47 to 1.76 | 0.33 -0.41 to 1.29 | 0.38 -1.21 to 2.39 | 0.30 -1.30 to 2.37 | 0.03 -1.27 to 1.65 | INS_GLARGINE | -0.09 -1.22 to 1.25 | -0.13 -1.02 to 0.80 |
| EXEN_SC | -0.74 -1.77 to 1.03 | 1.48 -0.16 to 2.83 | 1.23 -0.24 to 2.80 | 1.08 -0.53 to 3.05 | 0.64 -1.30 to 2.13 | 0.51 -0.60 to 1.92 | 0.42 -0.52 to 1.34 | 0.44 -1.32 to 2.59 | 0.37 -1.45 to 2.49 | 0.10 -1.40 to 1.83 | 0.09 -1.25 to 1.22 | EXEN_SC | -0.04 -1.60 to 1.38 |
| ALBI_SC | -0.69 -1.73 to 1.22 | 1.52 0.15 to 2.72 | 1.27 -0.17 to 3.07 | 1.16 -0.44 to 3.15 | 0.69 -1.03 to 2.07 | 0.56 -0.61 to 2.18 | 0.46 -0.67 to 1.75 | 0.51 -1.28 to 2.67 | 0.43 -1.36 to 2.59 | 0.15 -1.31 to 2.02 | 0.13 -0.80 to 1.02 | 0.04 -1.38 to 1.60 | ALBI_SC |
Heterogeneity, fit and convergence
Bayesian random effects (primary)
Frequentist check (netmeta)
Inconsistency
Do trials comparing two treatments directly agree with the indirect evidence through other treatments?
No comparison here has both direct and indirect evidence, so inconsistency cannot be checked by node splitting; the between designs Q above is the global check.
Small study effects
A comparison adjusted funnel plot: each point is one trial comparison, centered on its own network estimate. Asymmetry can signal that small trials with unfavorable results are missing.
Fewer than ten trial comparisons, too few to judge funnel plot asymmetry.
Baseline characteristics of the trials
The baseline value of each effect modifier or prognostic factor that applies here, per trial: mean or percent over arms, weighted by the number randomized. A note under a value names a stand in (a median for a mean, 100 minus the male share, Asian subgroup rows, an all Asian site list); "not reported" means no source of the trial prints it.
| Trial | Baseline HbA1c (percent) effect modifier, prognostic factor; 12 of 12 | Background glucose lowering therapy (stratum S0 to S4) effect modifier, prognostic factor; 12 of 12 | Diabetes duration (years) effect modifier, prognostic factor; 11 of 12 | Asian ancestry or region (percent Asian) effect modifier, prognostic factor; 11 of 12 | Age (years) prognostic factor; 12 of 12 | Treatment duration (weeks) effect modifier; 12 of 12 |
|---|---|---|---|---|---|---|
| NCT00838916 S000099 | 8.31 | S1 | 8.73 | 5.13 Asian subgroup rows | 55.43 | 156 |
| PIONEER 4 S000133 | 7.98 | S1 | 7.6 | 13.4 | 56.2 | 52 |
| PIONEER 10 S000234 | 8.31 | S1 | 9.36 | 100 | 58.43 | 52 |
| SUSTAIN™ 3 S000329 | 8.34 | S1 | 9.2 | not reported | 56.55 | 56 |
| ACHIEVE-3 S000438 | 8.29 | S1 | 8.7 | 11.9 | 53.93 | 52 |
| NCT04093752 S000909 | 8.71 | S1 | 7.63 | 97.27 | 54.13 | 40 |
| AWARD-2 S001130 | 8.14 | S1 | 9.1 | 16.91 | 56.66 | 78 |
| PIONEER 7 S001153 | 7.93 | S1 | 8.71 | 15.08 | 57.64 | 104 |
| NCT05486065 S001555 | 8.35 | S1 | 6.96 | 1.49 | 52.76 | 40 |
| SURPASS-3 S001591 | 8.17 | S1 | 8.4 | 5.4 | 57.4 | 52 |
| SUSTAIN 8 S001847 | 8.25 | S1 | not reported | 15.86 | 56.6 | 52 |
| AWARD-1 S002153 | 8.07 | S1 | 8.77 | 2.45 | 55.65 | 52 |
Comparability of the trials
Checked across designs (the set of treatments each trial compares) for eligibility, outcome definition and assessment, and the baseline factors above. Flags point to possible intransitivity; notes describe variation that is not tied to design.
- FlagBaseline, Baseline HbA1c: design means range from 7.9 (SEMA_PO vs SITAGLIPTIN) to 8.7 (INS_GLARGINE vs TIRZ_SC) percent; threshold 0.5
- FlagBaseline, Asian ancestry or region: design means range from 1.5 (PLACEBO vs SEMA_SC) to 100.0 (DULA_SC vs SEMA_PO) percent Asian; threshold 30
- FlagBaseline, Treatment duration: design means range from 40.0 (INS_GLARGINE vs TIRZ_SC) to 156.0 (ALBI_SC vs INS_GLARGINE) weeks; threshold 26
- FlagHeterogeneity, tau above threshold: tau 0.31 exceeds the outcome threshold 0.3; the flags of this network are candidate explanations
- NoteOutcome assessment, time point: selected time points span 40 to 56 weeks
- NoteOutcome assessment, analysis set: mixed: full_analysis 5, modified_itt 6, randomized 1
- NoteOutcome assessment, intercurrent events (discontinuation): mixed: hypothetical 8, not stated 4
- NoteOutcome assessment, intercurrent events (rescue): mixed: hypothetical 11, not stated 1
- NoteRisk of bias, blinding: mixed: double_blind 4, open_label 7, single_blind 1
- NoteData handling, input conversions: arms_combined 7
| Trial | time weeks | analysis set | definition | instrument | adjudicated | proportion method | intercurrent events (discontinuation) | intercurrent events (rescue) | blinding | funding | start year | Eligibility |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| NCT00838916 | 52 | modified_itt | not stated | not stated | not stated | not stated | not stated | hypothetical | open_label | industry | 2009 | age 18 or older, HbA1c 7.0 to 10.0 percent, BMI 20 to 45, creatinine clearance above 60 |
| PIONEER 4 | 52 | full_analysis | not stated | not stated | not stated | not stated | hypothetical | hypothetical | double_blind | industry | 2016 | Age 18 or older; T2D on metformin with or without SGLT2i; HbA1c 7.0 to 9.5 percent; eGFR 60 or more |
| PIONEER 10 | 52 | full_analysis | not stated | not stated | not stated | not stated | hypothetical | hypothetical | single_blind | industry | 2017 | Japanese adults 20 or older; T2D; HbA1c 7.0 to 10.5 percent on one oral glucose lowering drug |
| SUSTAIN™ 3 | 56 | full_analysis | not stated | not stated | not stated | not stated | hypothetical | hypothetical | open_label | industry | 2013 | age 18 or older; T2D on stable 1 to 2 oral drugs; HbA1c 7.0 to 10.5 percent; eGFR 60 or more |
| ACHIEVE-3 | 52 | modified_itt | not stated | not stated | not stated | not stated | hypothetical | hypothetical | open_label | industry | 2023 | adults T2D on metformin; HbA1c 7.0 to 10.5 percent |
| NCT04093752 | 40 | modified_itt | not stated | not stated | not stated | not stated | hypothetical | hypothetical | open_label | industry | 2019 | adults with T2D on metformin with or without sulfonylurea |
| AWARD-2 | 52 | modified_itt | not stated | not stated | not stated | not stated | not stated | hypothetical | open_label | industry | 2010 | type 2 diabetes on metformin and glimepiride |
| PIONEER 7 | 52 | randomized | not stated | not stated | not stated | not stated | hypothetical | hypothetical | open_label | industry | 2016 | age 18 or more; HbA1c 7.5 to 9.5 percent; one or two oral glucose lowering drugs |
| NCT05486065 | 40 | full_analysis | not stated | not stated | not stated | not stated | hypothetical | hypothetical | double_blind | industry | 2022 | age 18 to 64; HbA1c 7.0 to 10.5; BMI 27 or more; on metformin |
| SURPASS-3 | 52 | modified_itt | not stated | not stated | not stated | not stated | hypothetical | hypothetical | open_label | industry | 2019 | insulin naive; HbA1c 7.0 to 10.5 percent; BMI at least 25; metformin with or without SGLT2i; eGFR above 45 |
| SUSTAIN 8 | 52 | full_analysis | not stated | not stated | not stated | not stated | not stated | not stated | double_blind | industry | 2017 | age 18 or older; HbA1c 7.0 to 10.5 percent; eGFR 60 or higher; metformin 1500 mg or maximum tolerated |
| AWARD-1 | 52 | modified_itt | not stated | not stated | not stated | not stated | not stated | hypothetical | double_blind | industry | 2010 | adults with type 2 diabetes on metformin and pioglitazone |
Trial data
What each trial contributes. Arm rows give the arm value with its standard error, or events over participants; contrast rows give the mean difference on the analysis scale against the trial's first row. Flags mark converted, combined or approximated inputs.
| Trial | Arm | Treatment | Week | Data | Value | SE | Events / N | Flags | Source |
|---|---|---|---|---|---|---|---|---|---|
| NCT00838916 | A1 | ALBI_SC | 52 | arm, change | -0.670 | 0.044 | 493 | registry:outcomes | |
| NCT00838916 | A2 | INS_GLARGINE | 52 | arm, change | -0.790 | 0.064 | 238 | registry:outcomes | |
| PIONEER 4 | A1 | SEMA_PO | 52 | contrast, md | -1.400 | 0.102 | R0015836:Figure 2B | ||
| PIONEER 4 | A3 | PLACEBO | 52 | contrast, md | R0015836:Figure 2B | ||||
| PIONEER 10 | A1+A2+A3 | SEMA_PO | 52 | arm, change | -1.320 | 0.063 | 329 | arms_combined | R0018421:Figure 2D |
| PIONEER 10 | A4 | DULA_SC | 52 | arm, change | -1.300 | 0.100 | 56 | R0018421:Figure 2D | |
| SUSTAIN™ 3 | A1 | SEMA_SC | 56 | arm, change | -1.540 | 0.060 | 404 | registry:outcomes | |
| SUSTAIN™ 3 | A2 | EXENER_SC | 56 | arm, change | -0.920 | 0.060 | 405 | registry:outcomes | |
| ACHIEVE-3 | A1+A2 | ORFO_PO | 52 | arm, change | -2.034 | 0.039 | 648 | arms_combined | registry:outcomes |
| ACHIEVE-3 | A3+A4 | SEMA_PO | 52 | arm, change | -1.287 | 0.044 | 676 | arms_combined | registry:outcomes |
| NCT04093752 | A1+A2+A3 | TIRZ_SC | 40 | arm, change | -2.386 | 0.042 | 598 | arms_combined | registry:outcomes |
| NCT04093752 | A4 | INS_GLARGINE | 40 | arm, change | -0.950 | 0.073 | 193 | registry:outcomes | |
| AWARD-2 | A1+A2 | DULA_SC | 52 | arm, change | -0.919 | 0.043 | 530 | arms_combined | registry:outcomes |
| AWARD-2 | A3 | INS_GLARGINE | 52 | arm, change | -0.630 | 0.060 | 259 | registry:outcomes | |
| PIONEER 7 | A3 | SEMA_PO | 52 | contrast, md | -0.400 | 0.128 | R0023369:Results | ||
| PIONEER 7 | A4 | SITAGLIPTIN | 52 | contrast, md | R0023369:Results | ||||
| NCT05486065 | A1 | SEMA_SC | 40 | contrast, md | -2.000 | 0.459 | R0005510:Figure 1 | ||
| NCT05486065 | A4 | PLACEBO | 40 | contrast, md | R0005510:Figure 1 | ||||
| SURPASS-3 | A1+A2+A3 | TIRZ_SC | 52 | arm, change | -2.162 | 0.029 | 897 | arms_combined | R0007531:Table 2 |
| SURPASS-3 | A4 | INS_DEGLUDEC | 52 | arm, change | -1.340 | 0.050 | 317 | R0007531:Table 2 | |
| SUSTAIN 8 | A1 | SEMA_SC | 52 | arm, change | -1.700 | 0.055 | 394 | registry:outcomes | |
| SUSTAIN 8 | A2 | CANAGLIFLOZIN | 52 | arm, change | -1.000 | 0.050 | 394 | registry:outcomes | |
| AWARD-1 | A1+A2 | DULA_SC | 52 | arm, change | -1.216 | 0.057 | 540 | arms_combined | registry:outcomes |
| AWARD-1 | A3 | EXEN_SC | 52 | arm, change | -0.800 | 0.080 | 266 | registry:outcomes |
Rerun this analysis yourself
Remove treatments or trials and refit the frequentist and Bayesian models in your browser, with the same methods as the published analysis.