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Perspectives

New agents to treat type 2 diabetes

Ted Wu

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Abstract

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.

Key Points

  • 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.

    Picture credit: © BSIP/Diomedia

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