Is there a contraindication to using Jardiance (empagliflozin) and Januvia (sitagliptin) concurrently in patients with type 2 diabetes?

Concurrent Use of Jardiance (Empagliflozin) and Januvia (Sitagliptin)

There is no contraindication to using Jardiance (empagliflozin) and Januvia (sitagliptin) concurrently in patients with type 2 diabetes. 1, 2

Mechanism of Action and Complementary Effects

• SGLT2 inhibitors (Jardiance/empagliflozin): Work by increasing urinary glucose excretion through inhibition of sodium-glucose cotransporter 2 in the kidneys
• DPP-4 inhibitors (Januvia/sitagliptin): Work by inhibiting the enzyme that breaks down incretin hormones, thereby increasing insulin secretion and decreasing glucagon secretion

These medications have different and complementary mechanisms of action, making their combination pharmacologically sound.

Evidence Supporting Combination Therapy

The American College of Cardiology guidelines specifically address combination therapy with different classes of antidiabetic medications:

• While there are no specific cardiovascular outcome trials studying the combination of SGLT2 inhibitors and DPP-4 inhibitors (like sitagliptin), clinical guidelines support their concurrent use 1
• The American Diabetes Association guidelines recommend considering combination therapy with a DPP-4 inhibitor and an SGLT2 inhibitor for patients requiring multiple agents to achieve glycemic control 2

Clinical Considerations When Using Both Medications

Potential Benefits:

• Additive glycemic control through complementary mechanisms
• Empagliflozin offers cardiovascular benefits (reduced CV death, hospitalization for heart failure) 1, 3
• Weight-neutral effect of sitagliptin combined with weight loss effect of empagliflozin 2, 4
• Low risk of hypoglycemia with both agents when used without insulin or sulfonylureas 5, 4

Monitoring Recommendations:

• Hypoglycemia: Monitor for hypoglycemia, especially if the patient is also on insulin or sulfonylureas; dose adjustments of these medications may be required 1, 2
• Renal function: Both medications require renal monitoring; empagliflozin is not recommended when eGFR <45 mL/min/1.73 m² for glycemic control 1
• Genital mycotic infections: Patients on empagliflozin have increased risk; counsel on personal hygiene 1, 5
• Euglycemic diabetic ketoacidosis: Rare but serious risk with empagliflozin; educate patients about symptoms (nausea, vomiting, abdominal pain, dyspnea) 1, 2

Practical Approach to Combination Therapy

1. Assess baseline renal function: Ensure eGFR is appropriate for both medications
2. Consider cardiovascular status: Empagliflozin has proven CV benefits in patients with established cardiovascular disease 1, 3
3. Evaluate risk of genital infections: Higher risk with empagliflozin 5
4. Monitor for hypoglycemia: Especially if patient is on other glucose-lowering medications 2
5. Adjust concomitant medications: Consider reducing insulin dose by approximately 20% or weaning sulfonylureas if HbA1c is well-controlled 1, 2

Conclusion

The combination of Jardiance (empagliflozin) and Januvia (sitagliptin) is not contraindicated and may provide complementary benefits through different mechanisms of action. This combination is supported by clinical guidelines and can be effective for glycemic control while offering potential cardiovascular benefits from empagliflozin.