Department of Internal Medicine, Unit of Metabolic Disease, University of Padova, Padova, Italy.
Department of Endocrinology and Nutrition, University of Oviedo, Oviedo, Spain.
Diabetes Metab Res Rev. 2018 May;34(4):e2981. doi: 10.1002/dmrr.2981. Epub 2018 Feb 15.
The newer oral therapies for type 2 diabetes mellitus, dipeptidyl peptidase-4 (DPP-4) inhibitors and sodium glucose cotransporter 2 (SGLT2) inhibitors, have advantages over older agents. Dipeptidyl peptidase-4 inhibitors are weight neutral and have few adverse effects. Sodium glucose cotransporter 2 inhibitors have additional benefits: weight loss, blood pressure reduction, cardiovascular risk reduction, and renoprotective effects. Sodium glucose cotransporter 2 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 that they are within the limits of what is considered cost-effective in health care. We discuss the relative merits and drawbacks of these 2 classes and consider their roles in the treatment of type 2 diabetes mellitus. We suggest a number of patient profiles where early use of these agents could be used. We favour the use of SGLT2 inhibitors over DPP-4 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 favour 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 ketoacidosis. We favour DPP-4 inhibitors in those where side effects of other agents are of concern, the frail elderly population, and those with renal disease precluding SGTL2 inhibitor use.
新型 2 型糖尿病口服药物，二肽基肽酶-4（DPP-4）抑制剂和钠-葡萄糖协同转运蛋白 2（SGLT2）抑制剂，优于传统药物。DPP-4 抑制剂不增加体重，不良反应较少。SGLT2 抑制剂还有额外的获益：减轻体重、降低血压、降低心血管风险和肾脏保护作用。SGLT2 抑制剂增加了泌尿生殖系统感染的风险，并且可能有“血糖正常”糖尿病酮症酸中毒的风险。需要权衡这些药物与传统药物的获益，因为它们更昂贵；然而，一些分析表明，它们在医疗保健中被认为是具有成本效益的范围内。我们讨论了这两类药物的相对优缺点，并考虑了它们在 2 型糖尿病治疗中的作用。我们提出了一些患者的情况，这些患者可以早期使用这些药物。我们倾向于在血糖目标未达到时，将 SGLT2 抑制剂作为二甲双胍的附加治疗药物，而不是 DPP-4 抑制剂，因为它们具有相似的降糖效果，并且 SGLT2 抑制剂还有额外的获益。我们特别倾向于在需要额外减轻体重和降低血压的患者，以及心力衰竭或心血管疾病患者中使用 SGLT2 抑制剂。应该注意警告患者生殖器真菌感染的风险，并避免在有 SGLT2 相关酸中毒风险因素的患者中使用。我们倾向于在其他药物有副作用、体弱的老年患者和有 SGTL2 抑制剂使用禁忌的肾功能不全患者中使用 DPP-4 抑制剂。
