Can I prescribe Januvia (sitagliptin) and Farxiga (dapagliflozin) together for a patient with type 2 diabetes?

Combining Januvia (Sitagliptin) and Farxiga (Dapagliflozin) for Type 2 Diabetes Management

Yes, you can prescribe Januvia (sitagliptin) and Farxiga (dapagliflozin) together as they have complementary mechanisms of action and their combination is supported by clinical evidence and guidelines. 1, 2

Rationale for Combination Therapy

The combination of these medications offers several advantages:

• Complementary mechanisms of action:

  • Sitagliptin (DPP-4 inhibitor): Increases incretin levels, stimulating insulin secretion and inhibiting glucagon release
  • Dapagliflozin (SGLT2 inhibitor): Reduces renal glucose reabsorption, increasing urinary glucose excretion independent of insulin 2, 3

• Clinical evidence supports this combination:

  • FDA labeling for dapagliflozin specifically mentions its study in combination with sitagliptin 2
  • The combination provides additive glycemic control benefits 4

Clinical Benefits of This Combination

1. Enhanced glycemic control:

   • Combining agents with different mechanisms provides more robust HbA1c reduction
   • A real-world study showed significant HbA1c reduction from 8.9% to 7.2% with this combination 4

2. Cardiovascular and renal benefits:

   • SGLT2 inhibitors like dapagliflozin reduce cardiovascular events, heart failure hospitalizations, and CKD progression 1
   • This combination aligns with current guidelines prioritizing agents with proven cardiovascular and renal benefits 5

3. Weight management:

   • Dapagliflozin promotes weight loss through caloric loss via glucosuria 6
   • Sitagliptin is generally weight-neutral 3

4. Low hypoglycemia risk:

   • Both medications have low intrinsic risk of hypoglycemia when used together 7

Implementation Guidelines

1. Patient selection:

   • Ideal for patients not meeting glycemic targets on monotherapy
   • Particularly beneficial for patients with or at risk for cardiovascular disease or CKD 1
   • Appropriate for patients concerned about weight gain 5

2. Dosing considerations:

   • Standard dosing: Sitagliptin 100 mg once daily and dapagliflozin 5-10 mg once daily
   • Adjust sitagliptin dose in patients with renal impairment (25-50 mg for moderate-severe renal impairment) 3

3. Monitoring recommendations:

   • Check HbA1c after approximately 3 months to assess efficacy 5
   • Monitor renal function before and periodically during treatment 5
   • Watch for signs of genital mycotic infections or urinary tract infections 2

Important Precautions

• Renal function:

  • Dapagliflozin's glucose-lowering efficacy decreases when eGFR falls below 45 mL/min/1.73 m² 5
  • Not recommended in severe renal impairment (eGFR <30 mL/min/1.73 m²) 1

• Infection risk:

  • Increased risk of genital mycotic infections with dapagliflozin
  • Advise patients about personal hygiene and symptom recognition 1

• Euglycemic diabetic ketoacidosis:

  • Rare but serious risk with SGLT2 inhibitors
  • Educate patients about symptoms and when to seek medical attention 1

Conclusion

The combination of sitagliptin and dapagliflozin represents a rational approach to diabetes management with complementary mechanisms of action. Current guidelines support this combination therapy approach, especially for patients who need additional glycemic control beyond monotherapy and who may benefit from the cardiovascular and renal protective effects of SGLT2 inhibitors 1.