Table 1.
Patient characteristics influencing preferred use of dipeptidyl peptidase‐4 inhibitors or glucagon‐like peptide‐1 receptor agonists.
| Patient characteristics | DPP‐4 inhibitor therapy | GLP‐1RA therapy | Therapy with other antidiabetic drugs (as specified) |
|---|---|---|---|
| Glycaemic‐related | |||
| HbA1c | 0.5–1.0% above target* | 1.0–1.5% above target | >1.5% above target |
| Unsuitable: DPP‐4 inhibitor | |||
| Possible: GLP‐1RA | |||
| Preferred: insulin | |||
| FPG | 0–1.7 mmol/l (0–30 mg/dl) above target 42 | 1.1–3.9 mmol/l (20–70 mg/dl) above target | >3.9 mmol/l (70 mg/dl) above target |
| Liraglutide > exenatide 91 | Preferred: insulin 92 | ||
| Unsuitable: DPP‐4 inhibitor or GLP‐1RA 8 | |||
| PPG | Δ above preprandial >3.3 mmol/l (60 mg/dl) (±elevated FBG) 42 | Δ above preprandial >3.3–5.6 (60–100 mg/dl) | Δ above preprandial >5.6 mmol/l (100 mg/dl) insulin – prandial or mealtime 90, 92 |
| Exenatide > liraglutide 91 | |||
| Necessity to avoid hypoglycaemia* | Preferred | Preferred | Unsuitable: insulin or SUs |
| Non‐glycaemic‐related | |||
| Necessity to reduce body mass index | Preferred to insulin | Preferred to DPP‐4 inhibitor | Possible: metformin, pramlintide |
| Unsuitable: insulin, SUs and glitazones | |||
| Preference for oral treatment/injection phobia | Preferred over GLP‐1RAs and insulin | Not suitable | Suitable: SUs, if DPP‐4 inhibitors contraindicated |
| Inability or unwillingness for blood glucose self‐monitoring* | — | Preferred over insulin | Unsuitable: insulin |
| Sensitivity to gastrointestinal events | Suitable | Not suitable | Unsuitable: metformin, acarbose |
| Poor compliance* | Possible: (neutral) | Preferred: long‐acting GLP‐1RA | Unsuitable: insulin |
| Comorbidities | |||
| Renal insufficiency | Preferred: linagliptin | Preferred: liraglutide | Unsuitable: metformin (lactic acidosis) 90; sulphonylureas (hypoglycaemia) |
| Dose adjustment required for other DPP‐4 inhibitors 27, 29 | Possible: exenatide (mild/moderate renal impairment); exenatide once weekly (mild renal impairment) | ||
| Liver disease† | Suitable (except saxagliptin) | Suitable: (unlimited data) | Preferred: insulin |
| Unsuitable: secretagogues (severe hepatic disease) 90 | |||
| Cardiovascular disease | Preferred to insulin | Preferred | Preferred: metformin, acarbose |
| Unsuitable: intensive insulin therapy, SUs90 | |||
| Economics | |||
| Cost | Preferred over GLP‐1RA | More costly than DPP‐4 inhibitors, similar to insulin treatment (including blood glucose self‐monitoring) | Preferred: metformin, SUs |
Treatment choice should be in line with primary treatment goal of achieving glycaemic control and as an adjunct to lifestyle interventions, but patients' preferences and various patient, disease and drug characteristics 90 (such as susceptibility to side effects, potential for weight gain and hypoglycaemia) should be considered, where no preference for DPP‐4 inhibitor/GLP‐1RA is apparent. DPP‐4, dipeptidyl peptidase‐4; FBG, fasting blood glucose; FPG, fasting plasma glucose; GLP‐1RAs, glucagon‐like peptide‐1 receptor agonists; OADs, oral antidiabetic drugs; PPG, postprandial glucose; SU, sulphonylurea.
Targets refer to those established for individual patients. The American Association of Clinical Endocrinologists and American College of Endocrinology 93, and Amercian Diabetes Association/European Association for the Study of Diabetes 89, 90 provide standard recommendations on glycaemic targets. In some patients, the optimum treatment may be the result of a compromise between what is desirable and what can be realistically achieved. In these cases, the suggested glycaemic ranges may not fully apply.
Incretin therapy suitable unless history of pancreatitis 91.