Case Study in Diabetes: Use of DPP-4 inhibitors with GLP-1 agonists

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A 63-year-old man with type 2 diabetes was admitted to the hospital to undergo right robotic partial nephrectomy.
A 63-year-old man with type 2 diabetes was admitted to the hospital to undergo right robotic partial nephrectomy.
 

With regards to his pioglitazone use, he had no history of heart failure, and his ALT level was acceptable at the time of discharge at 25 U/L. Signs and symptoms of heart failure were reviewed with the patient. He stated that he will follow up with his primary care provider should signs and symptoms of heart failure occur.

There are no guidelines that support the combined use of a GLP-1 agonist (liraglutide) and a DPP-4 inhibitor (linagliptin). Initially, it was thought that this combination of drug classes would be advantageous, with the GLP-1 agonist increasing incretin levels, and the DPP-4 inhibitor enhancing the effect of endogenous incretins. However, studies have not shown the benefit of this combination. Without clear evidence, the combined use of a GLP-1 agonist and a DPP-4 inhibitor is not currently recommended. Additionally, both of these classes of drugs are more costly compared with diabetes agents in other classes. The patient stated that cost was not an issue for him. Furthermore, both of these drug classes have been associated with rare cases of acute pancreatitis, so it is unknown whether this combination of drug classes may potentiate this risk. This side effect was reviewed with the patient, and he denies having a history of pancreatitis.

 

The American Diabetes Association Standards of Medical Care in Diabetes (2017) recommends 2 specific diabetes medications, liraglutide and empagliflozin, to lower the risk of death in patients with both diabetes and cardiovascular disease (CVD). At time of discharge, the patient stated that he would discontinue linagliptin, and continue use of pioglitazone and liraglutide. He stated that he will follow up with his primary care provider to re-evaluate his creatinine and eGFR to determine if a lower dose of metformin 500 mg by mouth twice daily could be initiated. In addition, the patient was motivated to continue physical activity and eating a healthy diet after discharge to continue to lose weight.

Clinical Pearls

Linagliptin 5 mg by mouth once daily is acceptable in patients with renal impairment, and no dose adjustment is required.
It is not recommended to initiate metformin with eGFR<45 mL/min.
Use of GLP1/DPP4 medications in combination is currently not supported.
The American Diabetes Association Standards of Medical Care in Diabetes (2017) recommends 2 specific diabetes medications, liraglutide and empagliflozin, to lower the risk of death in patients with both diabetes and CVD.


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