SGLT2 inhibitor or GLP-1 receptor agonist in type 2 diabetes?

Abstract

Among the newest glucose-lowering agents for the treatment of type 2 diabetes, two classes raise much interest: glucagon-like peptide-1 (GLP-1) receptor agonists and sodium-glucose cotransporter type 2 (SGLT2) inhibitors. Indeed, both showed a cardiovascular protection in dedicated outcome studies in patients with type 2 diabetes at high cardiovascular risk. 1 Scheen AJ Cardiovascular outcome studies in type 2 diabetes: comparison between SGLT2 inhibitors and GLP-1 receptor agonists. Diabetes Res Clin Pract. 2018; 143: 88-100 Summary Full Text Full Text PDF PubMed Scopus (35) Google Scholar , 2 Zelniker TA Wiviott SD Raz I et al. Comparison of the effects of glucagon-like peptide receptor agonists and sodium-glucose cotransporter 2 inhibitors for prevention of major adverse cardiovascular and renal outcomes in type 2 diabetes mellitus. Circulation. 2019; 139: 2022-2031 Crossref PubMed Scopus (273) Google Scholar These findings had a major effect on the newer guidelines for the management of type 2 diabetes. In patients with atherosclerotic cardiovascular disease, guidelines now recommend, after failure of metformin monotherapy, the addition of a GLP-1 receptor agonist or an SGLT2 inhibitor that was shown to reduce the risk of major cardiovascular events. 3 Davies MJ D'Alessio DA Fradkin J et al. Management of hyperglycaemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia. 2018; 61: 2461-2498 Crossref PubMed Scopus (604) Google Scholar In the absence of heart failure or renal disease, two conditions in which SGLT2 inhibitors appear more protective, 2 Zelniker TA Wiviott SD Raz I et al. Comparison of the effects of glucagon-like peptide receptor agonists and sodium-glucose cotransporter 2 inhibitors for prevention of major adverse cardiovascular and renal outcomes in type 2 diabetes mellitus. Circulation. 2019; 139: 2022-2031 Crossref PubMed Scopus (273) Google Scholar the clinician can choose between these two pharmacological options without specific guidance in the absence of comparative trials. 3 Davies MJ D'Alessio DA Fradkin J et al. Management of hyperglycaemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia. 2018; 61: 2461-2498 Crossref PubMed Scopus (604) Google Scholar Efficacy and safety of once-weekly semaglutide versus daily canagliflozin as add-on to metformin in patients with type 2 diabetes (SUSTAIN 8): a double-blind, phase 3b, randomised controlled trialOnce-weekly semaglutide 1·0 mg was superior to daily canagliflozin 300 mg in reducing HbA1c and bodyweight in patients with type 2 diabetes uncontrolled on metformin therapy. These outcomes might guide treatment intensification choices. Full-Text PDF