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CLINICAL CASE VIGNETTE: Antihyperglycemic Treatments

Jul 14, 2018
 

Mr. Huang is a 61-year-old Asian American businessman who comes in to see you for a follow-up appointment. He was diagnosed with type 2 diabetes four years ago and has a long-standing history (15 years) of hypertension and hypercholesterolemia, which are currently well-controlled. Current medications are metformin (1500 mg/day), lisinopril, and simvastatin. He has excess weight (BMI 29 kg/m2) but feels he has a healthy diet and gets out for a 25-30 minute walk 3 or 4 times per week. He feels great, but over the last nine months or so, he has noticed that his home average glucose levels are in the 180-198 mg/dL range. At today’s visit, his A1C is 8.3%.

Based on Mr. Huang’s individual glycemic target of A1C<7%, you would like to add another antihyperglycemic. You choose linagliptin over glimepiride. What is the best reason for your choice?

Correct

Answer: A. Greater weight loss benefits

Educational Critique: The DPP-4 inhibitors are considered to be weight loss-weight neutral, but have intermediate A1C lowering efficacy and are costly. In general, the noninsulin pharmacological agents metformin, sulfonylureas, TZDs and GLP-1 agonists are thought to have better glucose-lowering abilities than meglitinides, DPP-4 inhibitors, AGIs, colesevelam, or bromocriptine (respective expected A1C reduction 1.0-1.5% vs. 0.5-1.0%). However, studies have shown the differential effects on glucose control are small. Thus, when progressing from a monotherapy to a two-drug combination, selection of the second agent should be guided by agent- and patient-specific properties (e.g., dosing, costs, side-effects, weight impact).

In Mr. Huang’s case, he would benefit from the weight neutral/loss associated with the DPP-4 inhibitors as opposed to the sulfonylurea-associated weight gain. An efficacy study of Tradjenta (linaglipitin) vs. glimepiride in combination with metformin found, “Patients treated with linagliptin had a mean baseline body weight of 86 kg and were observed to have an adjusted mean decrease in body weight of 1.1 kg at 52 weeks and 1.4 kg at 104 weeks. Patients on glimepiride had a mean baseline body weight of 87 kg and were observed to have an adjusted mean increase from baseline in body weight of 1.4 kg at 52 weeks and 1.3 kg at 104 weeks (treatment difference p<0.0001 for both timepoints).”

Incorrect