From the Guidelines
The decision to initiate a GLP-1 receptor agonist versus an SGLT2 inhibitor should be based on the patient's specific health needs, with GLP-1 receptor agonists preferred for patients with established atherosclerotic cardiovascular disease or high risk of major adverse cardiovascular events (MACE), and SGLT2 inhibitors preferred for patients with heart failure with reduced ejection fraction (HFrEF) or chronic kidney disease (CKD) 1. When considering the indications for initiating a GLP-1 receptor agonist versus an SGLT2 inhibitor, several factors come into play.
Key Considerations
- The presence of established atherosclerotic cardiovascular disease (ASCVD) or high risk of MACE, where GLP-1 receptor agonists have shown significant benefit 1
- The presence of HFrEF or CKD, where SGLT2 inhibitors have demonstrated a reduction in hospitalization for heart failure, MACE, and cardiovascular death 1
- The patient's individualized HbA1c target and baseline HbA1c level, although the decision to treat with a GLP-1 receptor agonist or SGLT2 inhibitor should be considered independently of these factors 1
GLP-1 Receptor Agonist Recommendations
- Patients with type 2 diabetes and established ASCVD, such as those with prior myocardial infarction, ischemic stroke, or revascularization of coronary, carotid, or peripheral arteries, may benefit from GLP-1 receptor agonists to reduce MACE 1
- Patients with type 2 diabetes without established ASCVD but with indicators of high risk, such as coronary, carotid, or lower extremity artery stenosis >50%, left ventricular hypertrophy, eGFR <60 mL min–1 [1.73 m]–2, or albuminuria, may also benefit from GLP-1 receptor agonists 1
SGLT2 Inhibitor Recommendations
- Patients with type 2 diabetes and HFrEF, or those with CKD (eGFR 30 to ≤60 mL min–1 [1.73 m]–2 or UACR >30 mg/g), may benefit from SGLT2 inhibitors to reduce hospitalization for heart failure, MACE, and cardiovascular death 1
- Patients with type 2 diabetes and CKD may also benefit from SGLT2 inhibitors to prevent the progression of CKD 1 Ultimately, the decision to initiate a GLP-1 receptor agonist versus an SGLT2 inhibitor should be made on a case-by-case basis, taking into account the patient's specific health needs and individualized treatment goals 1.
From the FDA Drug Label
OZEMPIC is a glucagon-like peptide 1 (GLP-1) receptor agonist indicated as: • an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus (1). • to reduce the risk of major adverse cardiovascular events in adults with type 2 diabetes mellitus and established cardiovascular disease (1) JARDIANCE is a sodium-glucose co-transporter 2 (SGLT2) inhibitor indicated: To reduce the risk of cardiovascular death and hospitalization for heart failure in adults with heart failure. (1) To reduce the risk of cardiovascular death in adults with type 2 diabetes mellitus and established cardiovascular disease. (1) As an adjunct to diet and exercise to improve glycemic control in adults and pediatric patients aged 10 years and older with type 2 diabetes mellitus. (1)
The indications for initiating a GLP-1 receptor agonist versus an SGLT2 inhibitor are:
- GLP-1 receptor agonist:
- Improve glycemic control in adults with type 2 diabetes mellitus
- Reduce the risk of major adverse cardiovascular events in adults with type 2 diabetes mellitus and established cardiovascular disease 2
- SGLT2 inhibitor:
- Reduce the risk of cardiovascular death and hospitalization for heart failure in adults with heart failure
- Reduce the risk of cardiovascular death in adults with type 2 diabetes mellitus and established cardiovascular disease
- Improve glycemic control in adults and pediatric patients aged 10 years and older with type 2 diabetes mellitus 3
From the Research
Indications for Initiating GLP-1 Receptor Agonists
- GLP-1 receptor agonists are recommended as the preferred first injectable glucose-lowering therapy for type 2 diabetes, even before insulin treatment, due to their effectiveness in reducing HbA1c, weight, and cardiovascular risk 4, 5, 6.
- They are particularly recommended for patients with pre-existing atherosclerotic vascular disease, such as those with previous cardiovascular events 4, 6.
- GLP-1 receptor agonists may also be considered for patients with obesity and advanced chronic kidney disease (estimated glomerular filtration rate <30 mL/min/1.73 m2) 6.
Indications for Initiating SGLT2 Inhibitors
- SGLT2 inhibitors are most effective if the estimated glomerular filtration rate is more than 60 ml per min per 1·73m2 at initiation and should be avoided where there is a risk of diabetic ketoacidosis 5.
- They are recommended for patients with heart failure (with reduced ejection fraction) or chronic kidney disease (with or without established cardiovascular disease) 5, 7.
- SGLT2 inhibitors have been shown to reduce the risk of admission to hospital for heart failure and reduce cardiovascular and all-cause mortality 5, 7.
Comparison between GLP-1 Receptor Agonists and SGLT2 Inhibitors
- Both GLP-1 receptor agonists and SGLT2 inhibitors have been shown to reduce major cardiovascular events in patients with type 2 diabetes and established cardiovascular disease 8, 7.
- The choice between a GLP-1 receptor agonist and an SGLT2 inhibitor should be guided by the individual patient's profile and the specificities of each molecule, such as the presence of heart failure or chronic kidney disease 8, 7.
- GLP-1 receptor agonists may be preferred for patients with established cardiovascular disease, while SGLT2 inhibitors may be preferred for patients with heart failure or chronic kidney disease 5, 7.