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Experts weigh pros, cons of second-line diabetes therapies
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PHILADELPHIA — Panelists at the Heart in Diabetes Clinical Education Conference presented their respective arguments for their choice of SGLT2 inhibitors vs. GLP-1 receptor agonists as second-line therapy after metformin.
Zachary T. Bloomgarden, MD, MACE, clinical professor of medicine at Icahn School of Medicine at Mount Sinai, made the case for SGLT2 inhibitors as the appropriate second-line therapy due to their cardiovascular and renal benefits.
“In a network meta-analysis comparing the SGLT2 inhibitors with GLP-1 receptor agonists, the former had a nonsignificantly better effect on mortality … and nonsignificantly better effect on cardiovascular mortality, but we certainly think heart failure is important, and here the SGLT2 inhibitors are clearly better [than GLP-1 receptor agonists],” Bloomgarden said.
“When [researchers in the EMPA-REG trial] looked at patients with CVD and acute kidney injury, about 6% of those receiving empagliflozin vs. approximately 8% of those on placebo developed acute renal failure. To me, that is a major cardiovascular-renal endpoint and something to really consider,” Bloomgarden said.
Richard E. Pratley, MD, associate medical director of research and education at the Florida Hospital Diabetes Institute, contended that GLP-1 receptor agonists are the better next option after metformin.
“[These agents] have superior efficacy, superior weight loss … have cardiovascular benefit … and they can be used in special populations, including people with chronic kidney disease and the elderly,” Pratley said.
To illustrate some of these points, he referenced the DURATION-8 study, which he said found an HbA1c change of -1.6% in the exenatide group and -1.4% in the dapagliflozin group from baseline. In addition, a recent network meta-analysis indicated that liraglutide was superior to SGLT-2 inhibitors for lowering HbA1c. In addition, semaglutide was associated with reducing body weight by 4 to 6 kg, which Pratley said was larger than that typically seen with SGLT-2 inhibitors.
Bloomgarden noted that data have suggested that GLP1 receptor agonists have what he called an “800-pound gorilla” — problems with adherence due to frequent injections.
However, Pratley objected, “We can also use them once weekly, as opposed to taking a pill, which I feel will address the issue of adherence." - by Janel Miller
Reference: Bloomgarden ZT, Pratley, RE. Should SGLT2 inhibitor or GLP-1 receptor agonists be the preferred first choice following metformin? Presented at: Heart in Diabetes Clinical Education Conference; July 13-15, 2018; Philadelphia.
Disclosures: Bloomgarden reports he receives consulting and advising fees from Astra Zeneca, Intarcia, Janssen, Merck, Novartis and Sanofi andspeaking fees from Amgen, Astra Zeneca, Janssen and Merck; and he owns stock in Allergan, Novartis and Zimer Biomet. Pratley reports he receives consulting fees Sanofi U.S. Services Inc.