Saturday’s Daily Piece: SGLT2 Inhibitor vs. GLP1 Agonist When Have Type 2 Diabetes and Heart Disease

In a person with type 2 diabetes and heart (cardiovascular) disease, it can be a tough choice as to whether to select SGLT2 inhibitor (empagliglozin, canagliflozin, dapagliflozin) or GLP-1 agonist (liraglutide, semaglutide, albiglutide) usually after starting or when starting metformin. I list these specific drugs within each of the two drug classes because they have been studied for their benefit heart disease and diabetes.

Favor SGLT2 inhibitor if person has heart failure; fear of needles and prefers oral medication; chronic kidney disease with eGFR (measures how the kidneys can filter the blood) >45 ml/min/1.73m2.

Caution or avoidance of SGLT2 inhibitor if person has a high risk for amputation; peripheral arterial disease (blood flow in legs and feet are not so good); history of diabetic ketoacidosis; osteoporosis or at risk of falls

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Favor GLP1 agonist if person is at risk for stroke or heart attack without a history of heart failure; peripheral arterial disease with ulcer, infection or prior amputation ; obesity

Caution or avoidance of GLP1 agonist if person has had a prior gastric surgery or known gastroparesis (because this class of drugs works in the stomach); eGFR <30 ml/min/1.73 m2 (kidney is not really able to do very well with filtering the blood) or end stage kidney disease; history of medullary thyroid cancer (or MEN2); diabetic proliferative retinopathy.

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Reference: Dhinsa DS, Mehta A, Sandesara PB, et al. Strategie for Appropriate Selection of SGLT2-i vs GLP1-RA in Persons with Diabetes and Cardiovascular Disease. Current Cardiology Reports (2019). 21:100.

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