Dr Darren K. McGuire Discusses Use of SGLT2 Inhibitors and GLP-1 Receptor Agonists in T2D

June 16, 2020

Many in the endocrinology community still endorse using metformin first in patients with type 2 diabetes, but that isn’t really necessary any more now that sodium-glucose transport protein 2 (SGLT2) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists are available, said Darren K. McGuire, MD, MHSc, professor of medicine in the Division of Cardiology, Dallas Heart Ball Chair for Research on Heart Disease in Women, Distinguished Teaching Professor, at the University of Texas Southwestern Medical Center.

Many in the endocrinology community still endorse using metformin first in patients with type 2 diabetes, but that isn’t really necessary any more now that sodium-glucose transport protein 2 (SGLT2) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists are available, said Darren K. McGuire, MD, MHSc, professor of medicine in the Division of Cardiology, Dallas Heart Ball Chair for Research on Heart Disease in Women, Distinguished Teaching Professor, at the University of Texas Southwestern Medical Center.

Transcript

Based on the evidence we have, for a patient with type 2 diabetes and other risk factors, is an SGLT2 inhibitor a therapy to be used earlier or later?

So, we have a lot of medications available for the treatment of hyperglycemia and type 2 diabetes—12 different classes of medications available in the US. And prioritizing their order of use is an ongoing conversation. If you don't have atherosclerotic cardiovascular disease, or multiple risk factors, then you enter an entire kind of nebulous space of you can choose almost anything you want. And depending on what your priorities are, and patient preferences, you can choose any number of therapies that have been proven both effective at lowering glucose and at least reasonably safe.

Once you get into the cardiovascular domain or advanced kidney disease domain that equation changes and very clearly, and it's endorsed across the across the Atlantic is that SGLT2 inhibitors and/or GLP-1 receptor agonists take precedence. If you have primarily atherosclerotic cardiovascular disease, they're relatively similar in the recommendation: choose one or the other one, depending on your preference and the patient’s. If you have heart failure and/or advanced kidney disease, as the EGFR [estimated glomerular filtration rate] allows, SGLT2 to is clearly the preferred therapy to start with.

All of this on the background of the endocrinology community still endorsing metformin as a first-line therapy. From a cardiology perspective, I don't think that's necessary any longer. If you have a clear indication for these cardiovascular risk-mitigating therapies, my approach is to start one of them, if you still need blood glucose control, start the other one. And then on both of these 2 medicines, if you still need additional glucose control, then metformin certainly is the next drug I choose. But the reality is I can get a lot of people well within their therapeutic target for glucose control just with an SGLT2 inhibitor and a GLP-1 receptor agonist, and so that mitigates the need for the Metformin or any other additional glucose-lowering medications.