When Metformin Is Not Enough: Pros and Cons of SGLT2 and DPP ‐4 Inhibitors as a Second Line Therapy

ABSTRACT The newer oral therapies for type 2 diabetes (T2DM); dipeptidyl peptidase‐4 (DPP‐4) inhibitors and sodium glucose cotransporter 2 (SGLT2) inhibitors have advantages over older agents. DPP‐4 inhibitors are weight neutral, and have few adverse effects. SGLT2 inhibitors have additional benefits; weight loss, blood pressure reduction, cardiovascular risk reduction, and renoprotective effects. SGLT2 inhibitors, have increased risk of urogenital infections and possible risk of “euglycaemic” diabetic ketoacidosis. It is important to balance the benefits over the older‐oral therapies as these agents are more expensive; yet some analyses suggest they are within the limits of what is considered cost‐effective in healthcare. We discuss the relative merits and drawbacks of these two classes and consider their roles in the treatment of T2DM. We suggest a number of patient profiles where early use of these agents could be employed. We favor the use of SGLT2 inhibitors over DPP4 inhibitors as add on therapy to metformin when glycaemic targets have not been achieved given their similar glycaemic efficacy and the additional benefits of SGLT2 inhibitors. We particularly favor SGLT2 inhibitors in those where additional weight loss and blood pressure reductions are desired, and in patients with heart failure or cardiovascular disease. Care should be taken to warn patients about genital fungal infections, and to avoid use in people with risk factors for SGLT2 associated ket...
Source: Diabetes/Metabolism Research and Reviews - Category: Endocrinology Authors: Tags: REVIEW ARTICLE Source Type: research