Case 1: Manuela
A 48-year-old Mexican female who presents for follow-up on a diagnosis of type 2 diabetes.
Click To Enter CaseCase 2: Zhang
A 72-year-old Chinese male who presents for routine follow-up appointment.
Click To Enter CaseCase 3: Jim
A 66-year-old male. He presents for an appointment following hospitalization for myocardial infarction.
Click To Enter CaseInteractive Case Study Operating Instructions
- Identifying the Pathway to Successful Patient Care: Practical Implementation of Incretin-Based Therapies in Type 2 Diabetes will present you with 3 interactive patient cases. You may choose to review each patient with type 2 diabetes in any order. Select a case from the left by clicking the 'Click To Enter Case' link. Once you enter the case and before answering questions, click on the patient’s tab to view his clinical presentation, medical history, and current medications.
- After reviewing each diabetes case, you will be asked about changes you would recommend to improve the patient’s glycemic control; you will be given the opportunity to compare your decisions with those of other participants and with the recommendations of our expert faculty.
- Each case will take approximately 30 minutes to complete.
- Use your mouse to click on your selected answers in each case.
- Upon completion of each case study, you will earn CME/CE credit and will be given the option to choose another case to earn more CEUs or exit the activity.
© Copyright 2012 CaringForDiabetes.com. All rights reserved.
| A1C | glycosylated hemoglobin |
| AACE | American Association of Clinical Endocrinologists |
| ACCORD | Action to Control Cardiovascular Risk in Diabetes |
| ACE | American College of Endocrinology |
| ADA | American Diabetes Association |
| ADOPT | A Diabetes Outcome Progression Trial |
| ADVANCE | Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation |
| AHF | acute heart failure |
| BMI | body mass index |
| BP | blood pressure |
| BUN | blood urea nitrogen |
| CHF | congestive heart failure |
| CI | confidence interval |
| Cr | serum creatinine |
| DPP-4 | dipeptidyl peptidase-4 |
| DURATION | Diabetes Therapy Utilization: Researching Changes in A1C, Weight, and Other Factors Through Intervention with Exanatide Once Weekly |
| EASD | European Association for the Study of Diabetes |
| FDA | Food and Drug Administration |
| FPG | fasting plasma glucose |
| GFR | glomerular filtration rate |
| GIP | glucose-dependent insulinotropic polypeptide |
| GLIM | glimepiride |
| GLP-1 | glucagon-like peptide-1 |
| GLY | glyburide |
| GWAA | Effects of AC2993 (Synthetic Exendin-4) Compared With Insulin Glargine in Patients With Type 2 Diabetes Also Using Combination Therapy With Sulfonylurea and Metformin |
| HCTZ | hydrochlorothiazide |
| HDL-C | high-density lipoprotein cholesterol |
| HEENT | head, eyes, ears, nose, and throat |
| HR | hazard ratio |
| LDL-C | low-density lipoprotein cholesterol |
| LEAD | Liraglutide Effect and Action in Diabetes |
| LEADER | Liraglutide Effect and Action in Diabetes: Evaluation of Cardiovascular Outcome Results - A Long Term Evaluation |
| LIRA | liraglutide |
| MET | metformin |
| MI | myocardial infarction |
| NHANES | National Health and Nutrition Examination Survey |
| NIDDM | non-insulin dependent diabetes mellitus |
| NPH | neutral protamine Hagedorn |
| OAD | oral antidiabetic drug |
| OR | odds ratio |
| PBO | placebo |
| PPG | postprandial plasma glucose |
| Rate R | rate ratio |
| Rel R | relative risk |
| RR | risk ratio |
| SBP | systolic blood pressure |
| SU | sulfonylurea |
| T2D | type 2 diabetes |
| T-C | total cholesterol |
| TG | triglycerides |
| TZD | thiazolidinedione |
| UACR | urinary albumin-to-creatinine ratio |
| UKPDS | United Kingdom Prospective Diabetes Study |
| US | United States |
| US FDA | United States Food and Drug Administration |
| VADT | Veterans Affairs Diabetes Trial |
| WBC | white blood cells |
Figure 1.1. Incretin Response Is Impaired in T2D[1]
![Figure 1.1. Incretin Response Is Impaired in T2D[1]](http://www.caringfordiabetes.com/case-studies/patient-care-incretin-based-therapies/resources/images/figure_1-1.jpg)
Figure 1.1. References
[1] Adapted from Nauck MA, et al. Diabetologia. 1986;29:46-52. Copyright © 1986 Springer-Verlag.
Figure 1.2. Injection Devices for GLP-1 Receptor Agonists[1-3]
![Figure 1.2. Injection Devices for GLP-1 Receptor Agonists[1-3]](http://www.caringfordiabetes.com/case-studies/patient-care-incretin-based-therapies/resources/images/figure_1-2.jpg)
Figure 1.2. References
[1] Byetta (5 mcg) pen user manual. Available at: http://pi.lilly.com/us/byetta_5_user%20manual.pdf.
[2] Byetta (10 mcg) pen user manual. Available at: http://pi.lilly.com/us/byetta_10_user%20manual.pdf.
[3] Victoza pen instructions. Available at: http://www.victoza.com/starting/using-your-pen.aspx.
Figure 2.1. Increasing Plasma Glucose With Progressing T2D Pathophysiology[1,2]
![Figure 2.1. Increasing Plasma Glucose With Progressing T2D Pathophysiology[1,2]](http://www.caringfordiabetes.com/case-studies/patient-care-incretin-based-therapies/resources/images/figure_2-1.jpg)
Figure 2.1. References
[1] Kendall DM, et al. Am J Med. 2009;122:S37-S50.
[2] LaSalle JR. Hosp Physician. 2005;46:37-42..
Figure 2.2. Higher GLP-1 Levels May Stimulate Central Nervous System Effects on Appetite and Food Intake [1]
![Figure 2.2. Higher GLP-1 Levels May Stimulate Central Nervous System Effects on Appetite and Food Intake [1]](http://www.caringfordiabetes.com/case-studies/patient-care-incretin-based-therapies/resources/images/figure_2-2.jpg)
Figure 2.2. Reference
[1] Holst JJ, Deacon CF, Vilsbøll T, Krarup T, Madsbad S. Trends Molec Med. 2008;14:161-168.
Figure 2.3. Nausea Is Less Persistent With Liraglutide Than With Exenatide
Figure 2.3. Reference
[1] Buse J, Rosenstock J, Sesti G, et al; LEAD-6 Study Group. Lancet. 2009;374:39-47.
Table 1.1. A1C Effects of Incretin-Based Therapies Used as Monotherapy
Incretin-Based Therapy |
Study Characteristics | A1C Change (%) Incretin-Based Therapy | A1C Change (%) Comparator |
| Exenatide [1] | N = 232, 24 weeks Baseline A1C = 7.8% T2D duration = 2 y |
5 mcg, 2 x daily: -0.7 10 mcg, 2 x daily: -0.9 |
PBO: -0.2 |
| Liraglutide [2] | N = 745, 52 weeks Baseline A1C = 8.2% T2D duration = 5.2-5.6 y |
1.8 mg, 1 x daily: -1.1 | GLIM: -0.5 |
| Saxagliptin [3] | N = 401, 24 weeks Baseline A1C = 7.9 T2D duration = 2.3-3.1 y |
2.5 mg, 1 x daily: -0.4 5.0 mg, 1 x daily: -0.5 |
PBO: 0.2 |
| Sitagliptin [4] | N = 1050, 24 weeks Baseline A1C = 7.2 T2D duration = 2.1-2.6 y |
100 mg, 2 x daily: -0.4 |
MET: -0.6 |
Table 1.1. References
[1] Moretto TJ, Milton DR, Ridge TD, et al. Clin Ther. 2008;30:1448-1460.
[2] Garber A, Ratner R, Garcia-Hernandez PA, et al; LEAD-3 (Mono) Study Group. Lancet. 2009;373:473-481.
[3] Rosenstock J, Aguilar-Salinas C, Klein E, Nepal S, List J, Chen R; CV181-011 Study Investigators. Diabetes Obes Metab. 2009;25:2401-2411.
[4] Aschner P, Katzeff HL, Guo H, et al; Sitagliptin Study 049 Group. Diabetes Obes Metab. 2010;12:252-261.
Table 1.2. A1C Effects of Incretin-Based Therapies Used as Add-On Therapies
Incretin-Based Therapy |
Background Therapy | Change in A1C (%) |
| Exenatide (10 mcg) | Sulfonylurea [1] | -0.9 |
| Metformin [2] | -0.8 | |
| Metformin + sulfonylurea [3] | -0.8 | |
| Metformin + thiazolidinedione [4] | -0.9 | |
| Liraglutide (1.8 mg) | Sulfonylurea [5] | -1.1 |
| Metformin [6] | -1.0 | |
| Metformin + thiazolidinedione [7] | -1.5 | |
| Metformin + sulfonylurea [8] | -1.3 | |
| Sitagliptin (100 mg) | Metformin [9,10] | -0.7 |
| Pioglitazone [11] | -0.9 | |
| Metformin + glimepiride [12] | -0.6 | |
| Saxagliptin (5.0 mg) | Metformin [13] | -0.7 |
| Thiazolidinedione [14] | -0.9 | |
| Glyburide [15] | -0.6 |
Table 1.2. References
[1] Buse JB, Henry RR, Han J, Kim DD, Fineman MS, Baron AD; Exenatide-113 Clinical Study Group. Diabetes Care. 2004;27:2628-2635.
[2] DeFronzo RA, Ratner RE, Han J, Kim DD, Fineman MS, Baron AD. Diabetes Care. 2005;28:1092-1100.
[3] Kendall DM, Riddle MC, Rosenstock J, et al. Diabetes Care. 2005;28:1083-1091.
[4] Zinman B, Hoogwerf BJ, García SD, et al. Ann Intern Med. 2007;30:477-485.
[5] Marre M, Shaw J, Brändle M, et al; LEAD-1 SU Study Group. Diabet Med. 2009;26:268-278.
[6] Nauck M, Frid A, Hermansen K, et al; LEAD-2 Study Group. Diabetes Care. 2009;32:84-90.
[7] Zinman B, Gerich J, Buse JB, et al; LEAD-4 Study Investigators. Diabetes Care. 2009;32:1224-1230.
[8] Russell-Jones D, Vaag A, Schmitz O, et al; LEAD-5 MET + SU Study Group. Diabetologia. 2009;52:2046-2055.
[9] Nauck MA, Meininger G, Sheng D, Terranella L, Stein PP; Sitagliptin Study 024 Group. Diabetes Obes Metab. 2007;9:194-205.
[10] Scott R, Loeys T, Davies MJ, Engel SS; Sitagliptin Study 801 Group. Diabetes Obes Metab. 2008;10:959-969.
[11] Rosenstock J, Brazg R, Andryuk PJ, Lu K, Stein P; Sitagliptin Study 019 Group. Clin Ther. 2006;28:1556-1568.
[12] Hermansen K, Kipnes M, Luo E, Fanurik D, Khatami H, Stein P; Sitagliptin Study 035 Group. Diabetes Obes Metab. 2007;9:733-745.
[13] DeFronzo RA, Hissa MN, Garber AJ, et al; Saxagliptin 014 Study Group. Diabetes Care. 2009;32:1649-1655.
[14] Hollander P, Li J, Allen E, Chen R; CV181-013 Investigators. J Clin Endocrinol Metab. 2009;94:4810-4819.
[15] Chacra R, Tan GH, Apanovitch A, Ravichandran S, List J, Chen R; CV181-040 Investigators. Int J Clin Pract. 2009;63:1395-1406.
Table 1.3. A1C Effects in Head-To-Head Studies of Incretin-Based Agents as Add-On Therapies [1-3]
Compared Agents |
Study Characteristics | A1C Change (%) |
| Liraglutide versus exenatide[1] |
N = 464, 26 weeks Baseline A1C = 8.2% Bckgd therapy: MET, SU, or MET+SU |
Liraglutide (1.8 mg daily): -1.12a Exenatide (10 mcg twice daily): -0.79 |
| Liraglutide versus sitagliptin[2] |
N = 658, 26 weeks Baseline A1C = 8.5% Bckgd therapy: MET |
Liraglutide (1.2 mg daily): -1.24b Liraglutide (1.8 mg daily): -1.50b Sitagliptin (100 mg daily): -0.90 |
| Saxagliptin versus sitagliptin[3] |
N = 801, 18 weeks Baseline A1C = 7.7% Bckgd therapy: MET |
Saxagliptin (5 mg daily): -0.52 Sitagliptin (100 mg daily): -0.62 |
| aP < .0001 vs exenatide. bP < .0001 vs sitagliptin. |
||
Table 1.3. References
[1] Buse JB, Rosenstock J, Sesti G, et al; LEAD-6 Study Group. Lancet. 2009;374:39-47.
[2] Pratley RE, Nauck M, Bailey T, et al; 1860-LIRA-DPP-4 Study Group. Lancet. 2010;375:1447-1456.
[3] Scheen AJ, Charpentier G, Ostgren CH, Hellqvist A, Gause-Nilsson I. Diabetes Metab Res Rev. 2010;26:540-549.
Table 1.4. Significant Effects of GLP-1 Receptor Agonists on Cardiovascular Risk Factors
Cardiovascular Risk Factor |
Exenatide[1] 3.5-year extension study |
Liraglutide[2,3] 26-week studies (6) |
| SBP (mm Hg) | -3.5 | - 2.6 |
| T-C (mg/dL) | -10.8 | -5.0 |
| LDL-C (mg/dL) | -11.8 | -7.7 |
| TG (mg/dL) | -44.4 | -17.7 |
Table 1.4. References
[1] Klonoff D, Buse J, Nielsen L, et al. Curr Med Res Opin. 2008;24:275-286.
[2] Fonseca F, Madsbad S, Falahati A, Zychma M, Plutzy J. ADA 69th Scientific Sessions; 545-P. Available at: http://professional.diabetes.org/Abstracts_Display.aspx?TYP=1&CID=73281.
[3] Plutzky J, Garber A, Toft AD, Poulter NR. EASD Meeting 2009; Abstract 762. Available at: http://www.abstractsonline.com/Plan/ViewAbstract.aspx?sKey=7f9239d6-f4a5-4fda-81c1-36d33cc9137f&cKey=a37bae24-6ca5-4e8a-bada-a1c93d00365a&mKey=%7bB3E385FB-2CC7-4F7C-8766-2F743C19F069%7d.
Table 1.5. Relative Risk of Pancreatitis With Incretin-Based Therapies: Large Database Analyses
| Agent | Comparator Group | Risk | 95% CI |
| Exenatide twice daily[1] (n = 27996) |
GLY or MET (n = 27983) |
RR: 1.0 | 0.6–1.7 |
| Exenatide twice daily[2] (n = 6545) |
MET, SU, or TZD/MET (n = 16244) |
HR: 0.9 | 0.6–1.5 |
| Exenatide twice daily[3] (n = 24237) |
OADs (n = 457797) |
OR: 0.95 | 0.65–1.38 |
| Exenatide twice daily[4] (n = 25719) |
OADs (n = 234536) |
Rate R: 0.5 | 0.2–0.9 |
| Sitagliptin[1] (n = 16276) |
GLY or MET (n = 16281) |
Rel R: 1.0 | 0.5–2.0 |
| Sitagliptin[2] (n = 15826) |
MET, SU, or TZD/MET (n = 16244) |
HR: 0.9 | 0.7–1.3 |
Table 1.5 References
[1] Dore D, Seeger J, Chan K. Curr Med Res Opin. 2009;25:1019-1027.
[2] Garg R, Chen W, Pendergrass M. Diabetes Care. 2010;33:2349-2354.
[3] Wenten M, Gaebler J, Hussein M, et al. ADA 70th Scientific Sessions; 596-P. Available at: http://professional.diabetes.org/Abstracts_Display.aspx?TYP=1&CID=79544.
[4] Bloomgren GL, Dore D, Wenten M, et al. ADA 70th Scientific Sessions; 543-P. Available at: http://professional.diabetes.org/Abstracts_Display.aspx?TYP=1&CID=79491.
Table 2.1. Gastrointestinal Adverse Effects With a-Glucosidase Inhibitors in US Placebo-Controlled Trials
| Abdominal Pain (% of patients) |
Diarrhea (% of patients) |
Flatulence (% of patients) |
|
| Miglitola [1] | 11.7 | 28.7 | 41.5 |
| Acarbosea [2] | 29 | 31 | 74 |
| aGastrointestinal adverse effects (eg, abdominal pain, diarrhea, flatulence) decrease over time. | |||
Table 2.1. References
[1] Glyset [miglitol] prescribing information. Available at: http://www.accessdata.fda.gov/drugsatfda_docs/label/2009/020682s008lbl.pdf.
[2] Precose [acarbose] prescribing information. Available at: http://www.accessdata.fda.gov/drugsatfda_docs/label/2008/020482s023lbl.pdf.
Table 2.2. Effects of Saxagliptin and Sitagliptin in Elderly Patients With T2D
| Saxagliptin [1] (5 mg/d) |
Sitagliptin [2] (50 or 100 mg/d)a |
|
| Study characteristics | Patients = 65 years Mono- or combination therapy N = 274 |
Patients = 65 years Monotherapy N = 206 |
| A1C Change vs PBO | -0.55% | -0.7% |
| Adverse Events | Similar to PBO | Similar to PBO |
| Hypoglycemia | None reported | Similar to PBO |
| aBased on creatinine clearance, per prescribing information. | ||
Table 2.2. References
[1] Maheux P, Doucet J, Allen E, et al. EASD Annual Meeting 2009 ;Abstract 766. Available at: http://www.abstractsonline.com/Plan/ViewAbstract.aspx?sKey=c528c81c-f95f-4042-9a65-493aa01da7d8&cKey=27d8fd9d-f5a5-4c4b-88cf-f87f7ed58c61&mKey=%7bB3E385FB-2CC7-4F7C-8766-2F743C19F069%7d.
[2] Barzilai N, Mahoney E, Guo H, et al. ADA 69th Scientific Sessions;587-P. Available at: http://professional.diabetes.org/Abstracts_Display.aspx?TYP=1&CID=73299.
Table 1.3. Characteristics of Incretin Hormones [1,2]
| GLP-1 | GIP |
| Stimulates glucose-dependent insulin secretion | |
| Rapidly degraded by DPP-4 | |
| Secreted by intestinal cells in response to nutrient ingestion | |
| Delays gastric emptying | Little effect on gastric emptying |
| Promotes satiety and reduces body weight | No significant effect on satiety or body weight |
| Inhibits glucagon secretion | Little effect on glucagon secretion |
Table 2.3. References
[1] Baggio L, Drucker D. Gastroenterology. 2007;132:2131-2157.
[2] Drucker DJ. Cell Metab. 2006;3:153-165.
Table 2.4. Hypoglycemia in Pivotal Incretin Therapy Trials
Incretin Therapy |
Sulfonylurea Status | Incidencea of Hypoglycemic Events (% of participants) |
Cases of Major Hypoglycemia (n) |
| GLP-1 Receptor Agonists | |||
| Exenatide[1] | Without SU | 3.8-10.7 | 0 |
| With SU | 14.4-35.7 | 1 | |
| Liraglutide[2] | Without SU | 3.6-9.7 | 1 |
| With SU | 7.5-27.4 | 6 | |
| DPP-4 Inhibitors | |||
| Sitagliptin[3] | Without SU | 0.6-3.9 | 1 |
| With SU | 12.2 | 0 | |
| Saxagliptin[4] | Without SU | 2.7-7.8 | NR |
| With SU | 13.3-14.6 | NR | |
| aOverall incidence of hypoglycemic events EXCEPT incidence of events requiring no assistance for liraglutide. | |||
Table 2.4. References
[1] Byetta [exenatide] prescribing information. Available at: http://pi.lilly.com/us/byetta-pi.pdf.
[2] Victoza [liraglutide] prescribing information. Available at: http://www.victozapro.com/pdf/Victoza_ComboPI_5.24.pdf.
[3] Januvia [sitagliptin] prescribing information. Available at: http://www.merck.com/product/usa/pi_circulars/j/januvia/januvia_pi.pdf.
[4] Onglyza [saxagliptin] prescribing information. Available at: http://packageinserts.bms.com/pi/pi_onglyza.pdf.
Table 2.5. Costs of Pharmacologic Agents Used for the Treatment of T2D[1-5]
Drug Class |
Drug Cost ($ per month, rounded to nearest $1) |
| Sulfonylureas | |
| Glipizidea | 13 |
| Glipizide, 24-h tabletsa | 15 |
| Glimepiridea | 15 |
| Glyburidea | 19 |
| Biguanides (Metformin)a | |
| Metformina | 32 |
| Metformin, 24-h tabletsa | 40 |
| a-Glucosidase Inhibitors | |
| Acarbosea | 82 |
| Miglitol | 102 |
| Human Insulinsd | |
| Regular human insulind | 67-73 (price dependent on brand) |
| NPH (isophane) insulind | 67-73 (price dependent on brand) |
| Long-Acting Insulin Analogues | |
| Insulin glargine | 112 |
| Insulin detemir | 110 |
| Rapid-Acting Insulin Analogues | |
| Insulin aspartb | 240 |
| Insulin lisprob | 226 |
| Insulin glulisineb | 201 |
| Pre-Mixed Insulin Analogues | |
| Aspart protamine/Aspart | 226 |
| Lispro protamine/lispro | 220 |
|
Glinides |
|
| Nateglinidea | 130-136 (price dependent on dose) |
| Repaglinide | 210-420 (price dependent on dose) |
| DPP-4 Inhibitors | |
| Sitagliptin | 216 |
| Saxagliptin | 203 |
| DPP-4 Inhibitor/Metformin | |
| Sitagliptin/metformin | 216 |
| Saxagliptin/metformin | Pricing not available |
| Thiazolidinediones | |
| Pioglitazone | 257 |
| Rosiglitazonee | 143-266 (price dependent on dose) |
|
Thiazolidinedione/Metformin |
|
| Pioglitazone/metformin | 257 |
| Rosiglitazone/metformine | 162 – 281 (price dependent on dose) |
| GLP-1 Receptor Agonists | |
| Exenatide | 280 |
| Liraglutide | 280 |
| Amylin Mimetics (Pramlintide) | 280-350 (price dependent on dose) |
| aPrice based on generic version. bPrice based on least expensive option for 5 X 3 mL pens. cPrice based on 100 U/mL, 10 mL vial. dRegular and NPH (isophane) human insulin not recommended per AACE/ACE guidelines.[6] eRosiglitazone use has been restricted by the US FDA.[7] |
|
Table 2.5. References
[1] Drugstore.com. Prescription price checker. Available at: http://www.drugstore.com/pharmacy/drugindex/default.asp?trx=1Z5015.
[2] VanDeKoppel S, Choe H, Sweet B. J Manag Care Pharm. 2008;14:363-380.
[3] Victoza [liraglutide] prescribing information. Available at: http://www.victozapro.com/pdf/Victoza_ComboPI_5.24.pdf.
[4] Onglyza [saxagliptin] prescribing information. Available at: http://packageinserts.bms.com/pi/pi_onglyza.pdf.
[5] Janumet [sitagliptin/metformin] tablets prescription information. Available at: http://www.merck.com/product/usa/pi_circulars/j/janumet/janumet_pi.pdf.
[6] Rodbard H, Jellinger P, Davidson J, et al. Available at: http://www.aace.com/pub/pdf/GlycemicControlAlgorithm.pdf.
[7] US FDA. FDA significantly restricts access to the diabetes drug Avandia. Available at: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm226975.htm.
Table 3.1. Dosing of incretin-based therapies
Agent |
Dose | Frequency | Administration Route | |
| GLP-1 receptor agonists | ||||
| Exenatide[1] | 5 or 10 mcg | Twice daily, before main meals |
Subcutaneous injection | |
| Liraglutide[2] | 1.2 or 1.8 mg | Once daily, independent of meals |
Subcutaneous injection | |
| DPP-4 inhibitors | ||||
| Sitagliptin[3] | 100 mg | Once daily, independent of meals |
Oral | |
| Saxagliptin[4] | 2.5 or 5 mg | Once daily, independent of meals |
Oral | |
Table 3.1. References
[1] Byetta [exenatide] prescribing information. Available at: http://pi.lilly.com/us/byetta-pi.pdf.
[2] Victoza [liraglutide] prescribing information. Available at: http://www.victozapro.com/pdf/Victoza_ComboPI_5.24.pdf.
[3] Januvia [sitagliptin] prescribing information. Available at: http://www.merck.com/product/usa/pi_circulars/j/januvia/januvia_pi.pdf.
[4] Onglyza [saxagliptin] prescribing information. Available at: http://packageinserts.bms.com/pi/pi_onglyza.pdf.
Table 3.2. Dosing incretin-based therapies in renal insufficiency
Renal Function |
GLP-1 Receptor Agonists | DPP-4 Inhibitors |
| Mild renal insufficiency (GFR > 50 mL/min) |
Exenatide: No change [1] Liraglutide: Use with caution due to limited clinical experience [2] |
Sitagliptin and saxagliptin: No changes [3,4] |
| Moderate renal insufficiency (GFR = 30-50 mL/min) |
Exenatide and liraglutide: Use with caution due to limited clinical experience [1,2] | Sitagliptin: decrease to 50 mg daily [3] Saxagliptin: decrease to 2.5 mg daily [4] |
| Severe renal insufficiency (GFR < 30 mL/min) |
Exenatide: Contraindicated [1] Liraglutide: Use with caution due to limited clinical experience [2] |
Sitagliptin: decrease to 25 mg daily[3] Saxagliptin: decrease to 2.5 mg daily[4] |
Table 3.2. References
[1] Byetta [exenatide] prescribing information. Available at: http://pi.lilly.com/us/byetta-pi.pdf.
[2] Victoza [liraglutide] prescribing information. Available at: http://www.victozapro.com/pdf/Victoza_ComboPI_5.24.pdf.
[3] Januvia [sitagliptin] prescribing information. Available at: http://www.merck.com/product/usa/pi_circulars/j/januvia/januvia_pi.pdf.
[4] Onglyza [saxagliptin] prescribing information. Available at: http://packageinserts.bms.com/pi/pi_onglyza.pdf.
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