What is the next medication to consider for a patient with Impaired renal function who cannot afford SGLT-2 (Sodium-Glucose Linked Transporter-2) inhibitors?

From the Guidelines

For patients with impaired renal function who cannot afford SGLT-2 inhibitors, a GLP-1 receptor agonist would be the next best medication to consider, as they provide cardiovascular and renal protection while effectively lowering blood glucose, with dulaglutide and semaglutide not requiring dose adjustment in renal disease 1.

Key Considerations

• GLP-1 receptor agonists, such as semaglutide (Ozempic, Rybelsus), dulaglutide (Trulicity), or liraglutide (Victoza), are good options for patients with impaired renal function who cannot afford SGLT-2 inhibitors, as they offer cardiovascular and renal protection while effectively lowering blood glucose 1.
• These medications can be used even in moderate to severe renal impairment, with dulaglutide and semaglutide not requiring dose adjustment in renal disease, making them particularly valuable for patients with renal impairment who often have multiple comorbidities 1.
• If cost remains a barrier, older agents like sulfonylureas (glipizide preferred over glyburide in renal impairment) or DPP-4 inhibitors (with appropriate dose adjustments) could be considered, although they may not offer the same level of cardiovascular and renal protection as GLP-1 receptor agonists 1.

Additional Benefits

• GLP-1 agonists work by increasing insulin secretion in a glucose-dependent manner, suppressing glucagon release, slowing gastric emptying, and reducing appetite, which can lead to weight loss and improved glycemic control 1.
• They also offer the additional benefits of cardiovascular risk reduction, making them particularly valuable for patients with renal impairment who often have multiple comorbidities 1.

Affordability Concerns

• Patient assistance programs from manufacturers may help address affordability concerns for these medications, and clinicians should prescribe generic medications when they are available rather than more expensive brand-name medications 1.

From the FDA Drug Label

TRULICITY has been studied in adults as monotherapy and in combination with metformin, sulfonylurea, metformin and sulfonylurea, metformin and thiazolidinedione, sodium-glucose co-transporter-2 inhibitors (SGLT2i) with or without metformin, basal insulin with or without metformin, and prandial insulin with or without metformin TRULICITY has also been studied in patients with type 2 diabetes mellitus and moderate to severe renal impairment.

The next medication to consider for a patient with impaired renal function who cannot afford SGLT-2 inhibitors is Dulaglutide (TRULICITY), as it has been studied in patients with type 2 diabetes mellitus and moderate to severe renal impairment.

• Key points:
  • Dulaglutide can be used as monotherapy or in combination with other medications.
  • It has been shown to reduce HbA1c levels in patients with type 2 diabetes.
  • A cardiovascular outcomes trial demonstrated that dulaglutide significantly reduced the risk of major adverse cardiovascular events 2.

From the Research

Next Medication Options

For a patient with impaired renal function who cannot afford SGLT-2 inhibitors, the following options can be considered:

• DPP-4 inhibitors, such as saxagliptin, which have been shown to be effective in reducing fasting and postprandial plasma glucose and hemoglobin A(1c) (HbA(1c)) levels 3
• The choice between a DPP-4 inhibitor and a SGLT2 inhibitor should be based on individual patient characteristics, with DPP-4 inhibitors being a better option for patients with renal impairment 4

Patient Characteristics to Consider

When choosing the next medication, the following patient characteristics should be taken into account:

• Presence of obesity or severe hyperglycaemia
• Elderly patient or frailty profile
• Presence of hypertension, hyperuricaemia, or antecedents of cardiovascular disease
• Risk of urinary/genital infections or events linked to dehydration such as hypotension 4

Combination Therapy

Combining a DPP-4 inhibitor with a SGLT2 inhibitor may be an attractive approach for patients with type 2 diabetes, as it can provide a more potent glucose-lowering effect than either monotherapy 5

• However, this option may not be feasible for patients who cannot afford SGLT-2 inhibitors, and therefore, DPP-4 inhibitors may be considered as an alternative 6, 4