May 1, 2018 Dr Chee L Khoo
When I wrote the article last fortnight about new SLT2 inhibitor/DPP4 inhibitor combo now on the PBS, the situation was still very confused. Since that article, more information has come to light. Yes, we are allowed to use both DPP4 inhibitors (DPP4i) and SLGT2 inhibitors (SGLT2i) together when patients with type 2 diabetes (T2D) if the HbA1c is >7.0%. Which agents you use depends on which agent your patient is currently on. This week I am going to try to clarify the incredibly confusing state of affairs with the SGLT2i/DPP4i combo saga.
Scenario 1 – Patient already on a DPP4 inhibitor
Patient with T2D on Metformin (+/- sulphonylurea) and a DPP4i and HbA1c >7.0%. You can add an SGLT2i. There are only two to choose from in Australia – Dapagliflozin (Forxiga®) or Empagliflozin (Jardiance®).
If the existing DPP4i is Saxagliptin (Onglyxa®), you can then switch the patient over to QTERN®) which is Dapaglifloxin + Saxagliptin but you need to add metformin separately.
If the existing DPP4i is Linagliptin (Trajenta®), then you can switch patient over to Glyxambi® which is Empaglifloxin + Linagliptin and once again, you need to add metformin separately.
If the patient is on any other DPP4i (Januvia®, Galvus® or Nesina®) or their metformin combo, then you can just add of the SGLT2i (Forxiga® or Jardiance®) to the existing DPP4i.
|Patient on DPP4 inhibitor (DPP4i)|
|Onglyxa®||Switch to QTERN® Plus Metformin|
|Trajenta®||Switch to Glyxambi® Plus Metformin|
|Others||Add Forxiga or Jardiance|
Scenario 2 – Patient already on an SGLT2i
Patient with T2D on Metformin (+/- sulphonylurea) and an SGLT2i (either Forxiga® or Jardiance®) and HbA1c >7.0%. You can just add any of the DPP4i (Onglyxa®), Trajenta®, Januvia®, Galvus® or Nesina®). But if Onglyxa® is your favourite DPP4i, then you can just switch patient to QTERN® plus metformin. Of if your favourite DPP4i is Trajenta®, then you can just switch patient to Glyxambi®.
|Patient on SGLT2i|
|Current SGLT2i||Your preferred DPP4i||Action|
|Forxiga®||Onglyxa®||Switch to QTERN® Plus Metformin|
|Jardiance®||Trajenta®||Switch to Glyxambi® Plus Metformin|
|Forxiga® or Jardiance®||Just add any other DPP4i (Januvia®, Galvus®, Nesina®)|