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Type 2 DiabetesPhase 4SMARTESTNCT03982381

SGLT2 Inhibitor or Metformin as Standard Treatment of Early Stage Type 2 Diabetes

A Phase 4 study testing Metformin and Dapagliflozin 10 MG in people with Type 2 Diabetes, run by Uppsala University at 1 site in Sweden.

Completed

Finished. The study has ended and is not enrolling. Results may be posted on the official record.

Official record
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Trial summary

A real-world, nationwide, register-based, randomised trial (RRCT) comparing SGLT2 inhibitors with metformin as standard treatment in early typ 2 diabetes. An open-label trial addressing efficacy with respect to clinically important macro- and microvascular events. Read more about this study

Who is it for?
Ages 18 years and older
Conditions the study is for
Type 2 Diabetes
What is being tested?
Metformin and Dapagliflozin 10 MG
Could I receive a placebo?
No, everyone receives an active treatment
How many people
2,067 participants
Where
1 siteSweden
Study dates
5 Sep 2019to 31 Jan 2026
Phase
Phase 4
Are there results?
None posted in the registry

Key requirements

Who can take part, as listed by the sponsor. Only the study team can confirm whether you are eligible, so take this list to your doctor.

  • Ages 18 years and older
  • All sexes
  • No healthy volunteers
  • Adult, Older adult

Who may be able to join

  • Men and women ≥18 years old
  • T2D (according to World Health Organization (WHO) criteria) of less than 4 years duration
  • BMI 18.5-45 kg/m2
  • Drug naïve or oral monotherapy with glucose-lowering drug.
  • Accepting NDR participation and other register data collection.

Who cannot join

  • Known or suspected other form of diabetes than type 2
  • Ongoing or more than >4 weeks in total of any previous treatment with: insulin, GLP-1 receptor agonists, SGLT2 inhibitors or combination of any diabetes medications
  • Medical need to start or intensify any specific GLD treatment, e.g. insulin due to marked hyperglycemia
  • HbA1c >70 mmol/mol for patients on monotherapy, >80 in drug naïve
  • Contraindication to either metformin or dapagliflozin, or any unacceptable risk with either treatment as assessed by the investigator
  • History or signs of established cardiovascular disease: diagnosis of myocardial infarction, angina pectoris, heart failure, stroke, lower extremity arterial disease, any limb amputation (except due to trauma or malignancy)
Show all 12Show fewer
  • Any serious illness or other condition with short life expectancy (<4 yr)
  • Renal impairment (eGFR <60 ml/min/1,73m2)
  • Any condition, as judged by the investigator, that suggests that the patient will be non-compliant or otherwise unsuitable to study medication or study participation
  • Pregnancy or breastfeeding, women of childbearing potential (WOCBP; including perimenopausal women who have had a menstrual period within 1 year) without adequate anticonception during any part of the study period
  • Involvement in the planning and/or conduct of the study
  • Ongoing participation in another clinical trial.

Trial locations and contacts

1 site in 1 country.

Sweden1 site
  • Uppsala University Hospital

    Uppsala, 75185

Other trials in Sweden

About this study

Official title: A Multicenter, Register-based, Randomized, Controlled Trial Comparing Dapagliflozin With Metformin Treatment in Early Stage Type 2 Diabetes Patients by Assessing Mortality and Macro- and Microvascular Complications

A real-world, nationwide, register-based, randomised trial (RRCT) comparing SGLT2 inhibitors with metformin as standard treatment in early typ 2 diabetes. An open-label trial addressing efficacy with respect to clinically important macro- and microvascular events.

Read the detailed description

2067 type 2 diabetes (T2D) patients on monotherapy or drug naive. Randomization 1:1, metformin, dosing according to treatment guidelines or SGLT2 inhibitor, dapagliflozin 10 mg od.

844 events estimated for study completion (90% power to detect hazard ratio (HR) <0.8 for dapagliflozin vs metformin ) Endpoint collection during study duration (about 4 years) from national health care registers: Patient, Prescribed drugs, Cause of death and Population registers; National diabetes register (NDR) Primary analysis according to insulin tolerance test (ITT)

Conditions
Type 2 Diabetes
Being tested
Metformin, Dapagliflozin 10 MG
Medical subject headings
Diabetes Mellitus, Type 2

What participants receive

What participants receive. In a randomised study each person is assigned to one group by chance.

  • MetforminDrug

    Active comparator

  • Dapagliflozin 10 MGDrug

    Experimental treatment

Study groups in NCT03982381
Study groupRoleWhat they receive
MetforminActive comparatorMetformin 1000-3000 mg per day according to clinical guidelines. Split into 2-3 doses per day.
Receives: Drug: Metformin
DapagliflozinExperimentalDapagliflozin 10 mg once daily
Receives: Drug: Dapagliflozin 10 MG

What is being measured

The primary outcome is the main question the study is designed to answer.

  1. Time to first occurence of a confirmed composite endpoint of death, myocardial infarction, stroke, heart failure, diabetic nephropathy, retinopathy or foot ulcer.

    A confirmed composite endpoint includes death, myocardial infarction, stroke, heart failure, diabetic nephropathy, retinopathy or foot ulcer (ICD10 diagnosis codes)

    Measured: Time to first event during study period (for each patient 24-48 months, mean 36 months )

Secondary outcomes (20)
  1. Ordinal analysis of components of primary endpoint (see above)

    Death, major adverse cardiovascular event or microvascular event at 2 years follow-up (ICD10 diagnosis codes), scored according to severity as specified in statistical analysis plan.

    Measured: Events of any of above having occurred during 48 months following randomization.

  2. Time to first occurence of a confirmed composite endpoint of death, myocardial infarction, stroke, heart failure, diabetic nephropathy, retinopathy or foot ulcer (ICD10 diagnosis codes) or initiation of insulin treatment.

    A confirmed composite endpoint includes death, myocardial infarction, stroke, heart failure, diabetic nephropathy, retinopathy or foot ulcer (ICD10 diagnosis codes) or initiation of insulin treatment (filled prescription according to Swedish Prescribed Drug Register)

    Measured: Time to first event during study period (for each patient 24-48 months, mean 36 months )

  3. Time to first occurence of a confirmed composite endpoint of non-fatal myocardial infarction, stroke, heart failure, unstable angina or cardiovascular death.

    A confirmed composite endpoint includes non-fatal myocardial infarction, stroke, heart failure, unstable angina or cardiovascular death (ICD10 diagnosis codes).

    Measured: Time to first event during study period (for each patient 24-48 months, mean 36 months )

  4. Time to first occurence of a confirmed composite endpoint of heart failure or cardiovascular death.

    A confirmed composite endpoint includes heart failure or cardiovascular death (ICD10 diagnosis codes)

    Measured: Time to first event during study period (for each patient 24-48 months, mean 36 months )

  5. Death

    Time to death (Population Register data)

    Measured: Time to event during study period (for each patient 24-48 months, mean 36 months)

  6. Microvascular events, first of; occurrence or progression of retinopathy, nephropathy, diabetic foot lesions

    Time to first event of: occurrence or progression of retinopathy, nephropathy, diabetic foot ulcers (ICD10 diagnosis codes)

    Measured: Time to first event during study period (for each patient 24-48 months, mean 36 months )

  7. Need for insulin treatment

    Time to initiation of insulin treatment (filled prescription according to Swedish Prescribed Drug Register)

    Measured: Time to first event during study period (for each patient 24-48 months, mean 36 months )

  8. Treatment failure, defined as add-on or switch to another glucose-lowering drug

    Time to event of: add-on or switch to another glucose-lowering drug (filled prescription according to Swedish Prescribed Drug Register)

    Measured: Time to first event during study period (for each patient 24-48 months, mean 36 months )

  9. Change in glycemic control

    HbA1c level (mmol/mol)

    Measured: Change during study period, at 12, 24, 36 and 48 months

  10. Change in LDL-cholesterol

    Change in LDL cholesterol from baseline (mmol/L)

    Measured: Change during study period; assessment at baseline, 12, 24, 36 and 48 months

  11. Change in HDL-cholesterol

    Change in HDL cholesterol from baseline (mmol/L)

    Measured: Change during study period; assessment at baseline, 12, 24, 36 and 48 months

  12. Change in total cholesterol

    Change in total cholesterol from baseline (mmol/L)

    Measured: Change during study period; assessment at baseline, 12, 24, 36 and 48 months

  13. Change in triglycerides

    Change in triglycerides from baseline (mmol/L)

    Measured: Change during study period; assessment at baseline, 12, 24, 36 and 48 months

  14. Change in albuminuria

    Change in urinary albumin/creatinine ratio (mg/mol)

    Measured: Change during study period; assessment at baseline, 12, 24, 36 and 48 months

  15. Change in blood pressure

    Change in systolic and diastolic blood pressure (mm Hg)

    Measured: Change during study period; assessment at baseline, 12, 24, 36 and 48 months

  16. Change in body weight

    Change in body weight (kg)

    Measured: Change during study period; assessment at baseline, 12, 24, 36 and 48 months

  17. Change in BMI

    Change in BMI (kg/m2)

    Measured: Change during study period; assessment at baseline, 12, 24, 36 and 48 months

  18. Health care costs

    Diagnosis-based (IDG) costs for all health care during study period plus medication cost

    Measured: Accumulated health care costs during study period (for each patient 24-48 months, mean 36 months )

  19. Health-related quality of life

    The Short Form 36-Item Survey version 1.0 (SF-36) is used for patient-reported health and consists of 36 questions. The weighted sums of scores in each of eight defined domains (relating to experience of different aspects of general health, symptoms and functions) are compiled into different scales according to a standardized algorithm. Each scale is directly transformed into a 0-100 scale on the assumption that each question carries equal weight. The lower the score the more disability. The higher the score the less disability, i.e. a score of zero is equivalent to maximum disability and a score of 100 is equivalent to no disability. We use the public domain version, called the the RAND-36 Item Health Survey.

    Measured: Assessment at baseline, 12, 24 months

  20. Health-related quality of life with respect to diabetes treatment satisfaction.

    The Diabetes Treatment Satisfaction Questionnaire (DTSQ) is used. It has been developed to assess patient satisfaction with diabetes treatment. The questionnaire is composed of two different factors. The first factor assesses treatment satisfaction and consists of six questions and the second factor consists of two questions, which assess the burden from hyper- and hypoglycemia. Treatment satisfaction is assessed as the sum of the scores of the six questions on the first factor (total score 36), with a higher score indicating higher treatment satisfaction.

    Measured: Assessment at baseline, 12, 24 months

Timeline

From the start of the study to its completion; the mark is today. Estimated dates are the sponsor’s plan.

  1. First posted11 Jun 2019
  2. Study start5 Sep 2019
  3. Primary completion31 Jan 2026
  4. Study completion31 Jan 2026

Resources

More details

For doctors and researchers: how the study is designed, who runs it, and its registry IDs.

Study design
Study type
Interventional
Phase
Phase 4
Primary purpose
Treatment
Allocation
Randomised
Intervention model
Parallel groups
Model description
Prospective randomized, open label, blinded endpoint design (PROBE). Multicenter study.
Masking
Single blind
Who is masked
Outcomes assessor
Enrolment
2,067 participants (actual)
IDs, dates and publications
ClinicalTrials.gov ID
NCT03982381
Sponsor's protocol ID
SMART-2019
Other IDs
2019-001046-17, 2019
Acronym
SMARTEST
Status last verified
Mar 2026
First submitted
27 May 2019
Last updated
4 Mar 2026
Results posted
No
Data monitoring committee
Yes
FDA-regulated drug
No
FDA-regulated device
No
Individual data sharing
No: IPD will be available to all scientific collaborators

Publications

  • Eriksson JW, Fanni G, Lundqvist MH, Jansson S, Radholm K, Sofizadeh S, Patsoukaki V, Nilsson A, Lindholm D, Rolandsson O, Norhammar A, Granstam E, Eliasson B, Bennet L, Sundstrom J. SGLT2 inhibitor or metformin as standard treatment in early-stage type 2 diabetes? Baseline data in SMARTEST, a novel, decentralised, register-based randomised trial on prevention of diabetic complications. Diabetes Obes Metab. 2026 Feb;28(2):1327-1338. doi: 10.1111/dom.70320. Epub 2025 Nov 28.

    PubMed 41311237
  • El-Damanawi R, Stanley IK, Staatz C, Pascoe EM, Craig JC, Johnson DW, Mallett AJ, Hawley CM, Milanzi E, Hiemstra TF, Viecelli AK. Metformin for preventing the progression of chronic kidney disease. Cochrane Database Syst Rev. 2024 Jun 4;6(6):CD013414. doi: 10.1002/14651858.CD013414.pub2.

    PubMed 38837240
  • Sundstrom J, Kristofi R, Ostlund O, Bennet L, Eliasson B, Jansson S, Leksell J, Almby K, Lundqvist M, Eriksson JW; SMARTEST study group (see list in Appendix). A registry-based randomised trial comparing an SGLT2 inhibitor and metformin as standard treatment of early stage type 2 diabetes (SMARTEST): Rationale, design and protocol. J Diabetes Complications. 2021 Oct;35(10):107996. doi: 10.1016/j.jdiacomp.2021.107996. Epub 2021 Jul 21.

    PubMed 34389234
  • Gnesin F, Thuesen ACB, Kahler LKA, Madsbad S, Hemmingsen B. Metformin monotherapy for adults with type 2 diabetes mellitus. Cochrane Database Syst Rev. 2020 Jun 5;6(6):CD012906. doi: 10.1002/14651858.CD012906.pub2.

    PubMed 32501595

Questions about this trial

What is this clinical trial studying?

A Phase 4 study testing Metformin and Dapagliflozin 10 MG in people with Type 2 Diabetes, run by Uppsala University at 1 site in Sweden.

The full registered description is in the About this study section and the official record.

Who may be eligible to take part?

The sponsor lists 5 inclusion and 12 exclusion criteria. Eligibility is decided by the study team after screening, so read the full criteria and contact a listed site.

Is this clinical trial currently recruiting?

The record says: finished, as of the sponsor's last update on 4 Mar 2026. Status can change between updates, so confirm with the study contact before making plans.

Where is the study taking place?

The record lists 1 site in Sweden. Whether a site is taking part right now should be confirmed with that site. See every site.

What are the possible benefits and risks?

They depend on the study and the treatment, and no study can promise a benefit. The study team explains the known risks during informed consent, before anyone joins; the record itself does not list them.

What does this phase mean?

Phase 4 studies take place after a treatment is approved, to learn more about its long-term benefits and risks in everyday use.

Not every study follows the same path, and some studies (observational studies, device studies) have no phase.

Are results available for this study?

The study is completed, but results are not available in the source record. That does not mean the treatment did or did not work.

How can a doctor refer a patient or contact the research team?

The record lists no contact. The official record names the sponsor, who can be asked directly. AzTrials does not enrol participants or take referrals.

What does the primary outcome measure?

Time to first occurence of a confirmed composite endpoint of death, myocardial infarction, stroke, heart failure, diabetic nephropathy, retinopathy or foot ulcer. (time frame: Time to first event during study period (for each patient 24-48 months, mean 36 months )). It is what the study was designed to measure, not a finding.

Where can I read the original study information?

On the ClinicalTrials.gov record for NCT03982381, which also lists 4 linked publications.

Does a listing mean the treatment is approved or proven to work?

No. A listing means the study is registered. It does not show that the treatment is safe, works, or is approved by a regulator.

How often is this information updated?

AzTrials copies changed records from ClinicalTrials.gov every night and reloads the whole registry every week. The sponsor last updated this record on 4 Mar 2026.

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