Network meta-analysis

HbA1c below 7 percent

Type 2 diabetes (adults); background therapy: one or more non insulin glucose lowering drugs

weeks 20 to 36 (target week 26)Treatment policyDoses of a drug pooledOdds ratio

Randomized trials

Treatments

4,361

Participants

2,109

Events

In plain language

Across 4 trials with 4,361 participants, 3 of 4 treatments had a clearly better result than placebo on HbA1c below 7 percent, and for 1 the evidence could not tell it apart from placebo. The most favorable estimate was for Dulaglutide injection: odds ratio 9.18 (95% credible interval 1.02 to 35.81).

Higher 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.

Node area shows participants; line width shows trials comparing two treatments directly. Blue: GLP-1 receptor agonist containing treatments; grey: comparators. Hover over or tab to a node or line for details.

Effects compared with Placebo

Odds ratio. Higher values favor the treatment.

Versus Placebo, log scale. Blue: Bayesian random effects posterior median with 95% credible interval (thick) and 95% prediction interval (dashed). Amber diamond: frequentist estimate with 95% confidence interval. Hover over or tab to a row for its values.

Effects of each treatment versus Placebo
Treatment	Bayesian OR (95% CrI)	95% prediction interval	Frequentist OR (95% CI)	Verdict
Dulaglutide injection DULA_SC	9.18 (1.02 to 35.81)	0.67 to 46.63	14.28 (3.66 to 55.70)	Better
Semaglutide tablet SEMA_PO	8.93 (1.80 to 22.76)	1.05 to 34.40	12.64 (4.87 to 32.80)	Better
Liraglutide injection LIRA_SC	7.62 (1.67 to 20.83)	1.00 to 32.30	9.78 (3.78 to 25.32)	Better
Sitagliptin SITAGLIPTIN	4.37 (0.70 to 13.31)	0.44 to 19.03	6.40 (2.10 to 19.51)	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: odds ratio of the row treatment versus the column treatment, posterior median and 95% credible interval. Green: row clearly better; red: row clearly worse.

Every treatment in a row compared with every treatment in a column
Row versus column	PLACEBO	DULA_SC	SEMA_PO	LIRA_SC	SITAGLIPTIN
PLACEBO	PLACEBO	0.11 0.03 to 0.98	0.11 0.04 to 0.56	0.13 0.05 to 0.60	0.23 0.08 to 1.43
DULA_SC	9.18 1.02 to 35.81	DULA_SC	1.04 0.25 to 3.24	1.22 0.17 to 5.42	2.12 0.43 to 8.86
SEMA_PO	8.93 1.80 to 22.76	0.97 0.31 to 4.02	SEMA_PO	1.18 0.32 to 3.35	2.03 0.91 to 4.94
LIRA_SC	7.62 1.67 to 20.83	0.82 0.18 to 5.87	0.84 0.30 to 3.10	LIRA_SC	1.71 0.51 to 8.38
SITAGLIPTIN	4.37 0.70 to 13.31	0.47 0.11 to 2.31	0.49 0.20 to 1.09	0.58 0.12 to 1.97	SITAGLIPTIN

Heterogeneity, fit and convergence

Bayesian random effects (primary)

Heterogeneity (tau): 0.422 (95% CrI 0.143 to 1.340), log scale
Residual deviance: 9.3 for 9 data points
DIC: 18.2 (pD 9.0)
Largest R-hat: 1.002
Smallest ESS: bulk 2,068, tail 2,110
Divergent transitions: 0
Convergence: All criteria met
Priors: PR02 N(0, 5^2); PR05 N(0, 2.5^2); PR09 log normal(-2, 1.58^2) on tau^2 (Biological markers (dichotomised), pharm vs pharm)

Frequentist check (netmeta)

Method: inverse variance, REML, OR
Tau: 0.399
I squared: 91%
Q (total): 11.74 on 1 df, P = 0.001
Q (between designs): 0.00

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.

Baseline effect modifiers and prognostic factors per trial
Trial	Baseline HbA1c (percent) effect modifier, prognostic factor; 4 of 4	Background glucose lowering therapy (stratum S0 to S4) effect modifier, prognostic factor; 4 of 4	Diabetes duration (years) effect modifier, prognostic factor; 3 of 4
PIONEER 4 S000133	7.98	S1	7.6
PIONEER 10 S000234	8.31	S1	9.36
PIONEER 12 S000522	8.12	S1	5.63
PIONEER 3 S002267	8.33	S1	not reported

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, Diabetes duration: not reported by 1 of 4 trials
FlagBaseline, Diabetes duration: design means range from 5.6 (SEMA_PO vs SITAGLIPTIN) to 9.4 (DULA_SC vs SEMA_PO) years; threshold 3
NoteOutcome assessment, definition: mixed: HbA1c below 7.0 percent 2, not stated 2
NoteOutcome assessment, proportion method: mixed: not stated 3, observed 1
NoteOutcome assessment, intercurrent events (discontinuation): mixed: hypothetical 3, not stated 1
NoteOutcome assessment, intercurrent events (rescue): mixed: hypothetical 3, not stated 1
NoteRisk of bias, blinding: mixed: double_blind 3, single_blind 1
NoteData handling, input conversions: arms_combined 3, count_from_percent 3

Comparability items per trial
Trial	time weeks	analysis set	definition	instrument	adjudicated	proportion method	intercurrent events (discontinuation)	intercurrent events (rescue)	blinding	funding	start year	Eligibility
PIONEER 4	26	full_analysis	not stated	not stated	not stated	observed	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	26	full_analysis	HbA1c below 7.0 percent	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
PIONEER 12	26	full_analysis	not stated	not stated	not stated	not stated	hypothetical	hypothetical	double_blind	industry	2019	adults with type 2 diabetes on metformin, HbA1c 7.0 to 10.5 percent
PIONEER 3	26	full_analysis	HbA1c below 7.0 percent	not stated	not stated	not stated	not stated	not stated	double_blind	industry	2016	adults with T2D; HbA1c 7.0 to 10.5 percent; metformin with or without sulfonylurea

Trial data

What each trial contributes. Arm rows give the arm value with its standard error, or events over participants; contrast rows give the odds ratio on the analysis scale (log) against the trial's first row. Flags mark converted, combined or approximated inputs.

Trial data entering this analysis
Trial	Arm	Treatment	Week	Data	Events / N	Flags	Source
PIONEER 4	A1	SEMA_PO	26	arm, responders	188 / 278	count_from_percent	R0015836:Figure 2C
PIONEER 4	A2	LIRA_SC	26	arm, responders	168 / 272	count_from_percent	R0015836:Figure 2C
PIONEER 4	A3	PLACEBO	26	arm, responders	19 / 134	count_from_percent	R0015836:Figure 2C
PIONEER 10	A1+A2+A3	SEMA_PO	26	arm, responders	260 / 384	arms_combined	R0018421:Table 4
PIONEER 10	A4	DULA_SC	26	arm, responders	45 / 64		R0018421:Table 4
PIONEER 12	A1+A2+A3	SEMA_PO	26	arm, responders	606 / 1,016	arms_combined	R0019776:Table 2
PIONEER 12	A4	SITAGLIPTIN	26	arm, responders	125 / 350		R0019776:Table 2
PIONEER 3	A1+A2+A3	SEMA_PO	26	arm, responders	554 / 1,396	arms_combined	registry:outcomes
PIONEER 3	A4	SITAGLIPTIN	26	arm, responders	144 / 467		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.

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