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Introduction
In Italy, 3.5 million people have been diagnosed with diabetes, over 90% of whom have type 2 diabetes mellitus (T2DM), with an estimated burden for the Italian national health system of approximately €8–10 billion yearly for drugs, hospitalizations and visits [1, 2].
Despite recent advances that have expanded the available therapeutic options, achieving and maintaining glycemic control in patients with T2DM remains a major challenge for doctors who must face complex therapeutic decisions [3]. The 2016 Italian Standard of Care [4], in line with the updated 2015 joint position statement released by the American Diabetes Association and European Association for the Study of Diabetes [5], recommends a patient-centered approach with metformin as the first line of therapy and the addition of one (or two) of the other available treatments as the second (or third) line of therapy, with no indicated preference. Doctors should make their initial decision based on the patient's physical and clinical characteristics and the efficacy and safety profiles of the available treatments and then address the eventual progressive worsening of glycemic control through treatment intensification.
Glucagon like peptide-1 receptor agonists (GLP-1 RAs) are a relatively new class of injectable drugs that have emerged as an attractive second- or third-line therapeutic option because of their association with improved glycemic control, lower hypoglycemia rate and weight loss, although gastrointestinal GLP-1 RAs side effects have also been reported [6, 7]. There are several GLP-1 RAs on the market in Europe, each with specific characteristics [3]; they vary in the magnitude of their effect in reducing HbA1c and enhancing weight loss and also in their adverse event profiles [3, 8]. Additionally, injection frequencies are variable, with some GLP-1 RAs offering more convenient dosing (weekly vs. daily injections) and potential higher adherence [9] compared with others. In Italy, the currently available GLP-1 RAs include exenatide twice daily (from now on referred to as exBID), launched February 2008; liraglutide once daily (LIRA), launched August 2010; exenatide once weekly (exQW) and lixisenatide once daily (LIXI), both launched December 2013 and dulaglutide (DULA) once weekly launched February 2016.
For a drug to be effective, patients must adhere to and persist with therapy. Previous studies have shown an association between better adherence and persistence with glucose-lowering treatments and improved clinical...