Empagliflozin and dulaglutide in type 2 diabetes
- April 6, 2021
|NZ is funding two medicines in new classes for the treatment of type 2 diabetes.1 These will be second line options after metformin, and favoured for patients at high risk of cardiovascular or renal complications. They are subject to special authority criteria.1-3 Empagliflozin, a sodium-glucose co-transporter-2 (SGLT2) inhibitor, is funded from 1 February 2021. Dulaglutide, a glucagon-like peptide-1 (GLP-1) receptor agonist, is awaiting registration with Medsafe.
Mechanisms of action
SGLT2 inhibitors (empagliflozin) increase urinary glucose excretion by inhibiting glucose uptake transporters in the renal proximal tubules.4
GLP-1 analogues (dulaglutide) are synthetic versions of a peptide hormone released by the gut into the portal circulation in response to food.5 They increase insulin and reduce glucagon secretion and slow gastric emptying.5,6
Place in therapy
Empagliflozin and dulaglutide are additional second line treatment options for the treatment of type 2 diabetes.7 Lifestyle changes and metformin remain first line treatment.
Patients who may particularly benefit from use
Both empagliflozin and dulaglutide reduce adverse outcomes associated with diabetes.8-11 SGLT2 inhibitors improve heart failure and reduce progression of diabetic kidney disease with albuminuria.2,3,11 GLP-1 analogues decrease weight more than other medicines for diabetes. Both have been shown to improve cardiovascular outcomes.
Neither cause hypoglycaemia, however, care should be taken if used concurrently with sulfonylureas or insulin. While their effect on blood pressure is modest, they can increase postural hypotension.
Table 1: Empagliflozin4,14
Table 2: Dulaglutide15
Empagliflozin has an increased risk of diabetic ketoacidosis (DKA) (~1/1000 years). It increases the risk of genitourinary infections, these are generally mild but rare cases of necrotising fasciitis are reported.
Dulaglutide frequently causes gastrointestinal symptoms such as nausea and anorexia, this is usually transient and improves with continued treatment. Occasionally the GI effects are severe and preclude use.
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