What is the role of Januvia (sitagliptin) and Jardiance (empagliflozin) in treating type 2 diabetes?

Role of Januvia (Sitagliptin) and Jardiance (Empagliflozin) in Type 2 Diabetes Management

For patients with type 2 diabetes and established cardiovascular disease or high cardiovascular risk, Jardiance (empagliflozin) should be prioritized over Januvia (sitagliptin) due to its proven cardiovascular mortality benefit and renal protective effects.

Comparison of Mechanisms and Benefits

Januvia (Sitagliptin)

• Mechanism: DPP-4 inhibitor that increases circulating incretins, stimulating insulin secretion and inhibiting glucose production 1
• Glycemic efficacy: Lowers HbA1c by approximately 0.5-0.8% 1
• Cardiovascular outcomes: Cardiovascular safety demonstrated but no proven cardiovascular benefit 2
• Cost: Relatively expensive at approximately $568 AWP for 100mg (maximum daily dose) 2

Jardiance (Empagliflozin)

• Mechanism: SGLT2 inhibitor that increases urinary glucose excretion 3
• Glycemic efficacy: Lowers HbA1c by approximately 0.7-1.0% 2
• Cardiovascular benefits:
  • Reduces cardiovascular death by 38% in patients with established cardiovascular disease 4, 5
  • Reduces hospitalization for heart failure by 35% 4
  • Reduces all-cause mortality by 32% 4, 5
• Renal benefits: Reduces progression of diabetic kidney disease 6, 7
• Cost: Approximately $627 AWP for 25mg (maximum daily dose) 2

Evidence-Based Treatment Algorithm

Step 1: Assess Patient's Cardiovascular and Renal Risk Status

For patients WITH established cardiovascular disease or high CV risk:

• First choice: Empagliflozin (Jardiance) 2
  • Reduces cardiovascular death, hospitalization for heart failure, and all-cause mortality
  • Benefits seen regardless of baseline HbA1c 2
  • Particularly beneficial in patients with heart failure (both HFrEF and HFpEF) 2, 4

For patients WITH chronic kidney disease:

• First choice: Empagliflozin (Jardiance) 2, 6, 7
  • Slows progression of kidney disease
  • Reduces risk of doubling of serum creatinine by 44% 6
  • Reduces need for renal replacement therapy by 55% 6

For patients WITHOUT established cardiovascular disease or CKD:

• Either medication may be appropriate based on:
  • Glycemic targets
  • Side effect profile
  • Cost considerations
  • Patient preferences

Step 2: Consider Combination Therapy When Needed

• If glycemic targets not achieved with metformin alone, either agent can be added 2
• For patients requiring multiple agents, consider combining mechanisms:
  • Metformin + SGLT2 inhibitor (empagliflozin) + DPP-4 inhibitor (sitagliptin) may be appropriate 2
  • Avoid combining DPP-4 inhibitors with GLP-1 receptor agonists due to similar mechanisms 2

Important Clinical Considerations

Safety Considerations

Jardiance (Empagliflozin):

• Caution in patients with:
  • Renal impairment (less effective with declining renal function) 7
  • Risk of volume depletion 8
  • Risk of genital infections 8, 5
• Monitor for:
  • Euglycemic diabetic ketoacidosis 2
  • Urinary tract infections
  • Hypotension

Januvia (Sitagliptin):

• Caution in patients with:
  • Severe renal impairment (dose adjustment required) 1
  • History of pancreatitis
• Monitor for:
  • Gastrointestinal side effects (up to 16%) 1
  • Joint pain

Common Pitfalls to Avoid

1. Failing to recognize cardiovascular benefit differences: Unlike empagliflozin, sitagliptin has not demonstrated cardiovascular mortality benefit 2

2. Overlooking renal function: Empagliflozin's glucose-lowering efficacy decreases with declining renal function, but cardiovascular benefits persist even in patients with eGFR as low as 30 mL/min/1.73m² 7

3. Ignoring cost considerations: Both medications are relatively expensive compared to older diabetes medications 2

4. Saxagliptin (another DPP-4 inhibitor) caution: Unlike sitagliptin, saxagliptin is not recommended in patients with high risk of heart failure 2

Conclusion

When choosing between Januvia (sitagliptin) and Jardiance (empagliflozin), the decision should be guided primarily by the patient's cardiovascular and renal risk profile. Empagliflozin offers clear mortality and cardiovascular benefits for patients with established cardiovascular disease, while sitagliptin offers cardiovascular safety without proven benefit. For patients without established cardiovascular disease or kidney disease, either medication may be appropriate based on individual factors and glycemic targets.