A 54-year old male presents to your office for an initial visit. His past medical history is significant for hypertension, hypertriglyceridemia and acute pancreatitis. His current lab results show an A1C 9.1%, which is confirmed on a repeat lab. You would like to start him on an antihyperglycemic treatment regimen. Which of the following two-drug combinations is contraindicated for this patient?
Answer: D. Metformin + a GLP-1 receptor agonist
Given this patient's A1C, initiating a 2-drug combination therapy would be an appropriate choice. The incretin-based drugs (GLP-1 receptor agonist and DPP-4 inhibitors) are contraindicated if there is a history of pancreatitis as they have been linked to reports of acute pancreatitis, although their possible role increasing the risk of pancreatitis is not clear. The GLP-1 receptor agonists are glucose dependent and work at the pancreatic level to stimulate insulin secretion and suppress glucagon production. DPP-4 inhibitors inhibit DDP-4 (DDP-4 inactivates the incretins), leading to an increase in active incretin levels.
Inzucchi S, et al. Management of hyperglycemia in type 2 diabetes: A patient-centered approach. Position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care. 2012; 35(6):1364-1379.