References
Evidence-based use of newer agents in type 2 diabetes
Abstract
The DPP-4 inhibitors, GLP-1 receptor agonists and SGLT-2 inhibitors are newer agents for glycaemic control in type 2 diabetes that can offer additional health benefits. All three treatments carry a low risk of hypoglycaemia. GLP-1 RAs and SGLT-2 inhibitors are associated with weight loss and DPP-4 inhibitors are weight neutral. The GLP-1 RAs and SGLT-2 inhibitors offer protection against cardiovascular events. SGLT-2 inhibitors are the agents of choice to add on to metformin for glycaemic control in chronic kidney disease and heart failure, with GLP-1 RAs an alternative to be considered if SGLT-2 inhibitors are poorly tolerated or contraindicated. DPP-4 inhibitors are very well tolerated. Gastrointestinal side-effects can be problematic with GLP-1 RAs though frequently these settle with time. Genital thrush is a common side-effect with SGLT-2 inhibitors and diabetic ketoacidosis is a rare but serious side-effect. It is important that healthcare professionals with responsibility in diabetes familiarise themselves with these treatments in order to know when and how to safely and effectively deploy them. The selection of newer agents should be based on careful assessment of individual circumstances. Overall, the standpoint has shifted from a largely glucocentric approach to one considering the impact of treatments on weight, risk of hypoglycaemia, and co-morbidities (notably atherosclerotic cardiovascular disease, heart failure and chronic kidney disease). Case histories are used in the article to illustrate the pragmatic use of these agents.
Recent accumulating evidence on the use of newer therapies in type 2 diabetes (T2DM) is helping to define their position in treatment. This information coupled with the increasing priority given toward individualisation of therapy can lead to more targeted use of drugs, utilising their benefits and taking account of their problems.
Overall the standpoint has shifted from a largely glucocentric approach to one considering the impact of treatments on weight, risk of hypoglycaemia, and co-morbidities (notably atherosclerotic cardiovascular disease (ASCVD), heart failure and chronic kidney disease (CKD). A truly patient-centred approach will also take account of personal circumstances and preferences (The National Institute for Health and Care Excellence (NICE), 2015; Scottish Intercollegiate Guidelines Network (SIGN), 2017; Davies et al, 2018).
This article reviews the properties of DPP-4 inhibitors, GLP-1 receptor agonists (GLP-1 RAs) and SGLT-2 inhibitors and their pragmatic use in T2DM.
Glucagon-like peptide-1 (GLP-1) is a key hormone secreted in response to the presence of food in the gut that facilitates a reduction in glucose levels by stimulating insulin secretion and suppressing glucagon secretion (Nauck and Meier, 2016). The DPP-4 inhibitors function by inhibiting the breakdown of endogenous GLP-1 by the enzyme dipeptidyl-peptidase-4 (DPP-4) thereby prolonging the glucose-lowering activity of GLP-1.
Register now to continue reading
Thank you for visiting Journal of Prescribing Practice and reading some of our peer-reviewed resources for prescribing professionals. To read more, please register today. You’ll enjoy the following great benefits:
What's included
-
Limited access to our clinical or professional articles
-
New content and clinical newsletter updates each month