The distinct pros and cons of three new classes of type 2 diabetes medication provide many options for individualised, safe treatment. Therapy may now be prescribed based on consideration of factors such as cardiac or renal protection, not only blood glucose lowering.
- In the past 10 years three new classes of diabetes medications have been introduced: the glucagon-like peptide-1 (GLP-1) receptor agonists; dipeptidyl peptidase-4 (DPP-4) inhibitors; and sodium–glucose cotransporter-2 (SGLT-2) inhibitors. None of these agents cause hypoglycaemia when used alone or in combination with metformin.
- GLP-1 receptor agonists have robust glycated haemoglobin- lowering properties and very good weight-reduction potential.
- GLP-1 receptor agonists are administered by injection, which may decrease their acceptability for some patients; exenatide can be given weekly, which may appeal to some patients.
- GLP-1 receptor agonists are not recommended in patients with significant renal disease.
- SGLT-2 inhibitors have many benefits including effective glucose lowering, blood pressure reduction and weight loss, and they have been shown to reduce hospitalisation for heart failure and improve renal outcomes.
- Empagliflozin has been shown to reduce cardiovascular death in patients with type 2 diabetes and prior cardiovascular disease.
- SGLT-2 inhibitors can only be used if the eGFR is adequate (>45 mL/min/1.73m2 for empagliflozin and >60mL/min/1.73m2 for dapagliflozin), and some patients may be unable to take them due to genital mycotic infections, polyuria or postural hypotension.
- DPP-4 inhibitors are a great alternative for patients with impaired renal function or who cannot tolerate other agents.
- DPP-4 inhibitors may offer slightly less glucose-lowering and weight-loss potential than the other new agents.
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