Are Januvia (sitagliptin) or Trulicity (dulaglutide) contraindicated in a person with Hypertension (HTN), diabetes, stroke, and heart disease?

Neither Januvia (Sitagliptin) nor Trulicity (Dulaglutide) Are Contraindicated in Patients with HTN, Diabetes, Stroke, and Heart Disease

Both medications can be safely used in patients with this clinical profile, with Trulicity actually being recommended for cardiovascular risk reduction in this population. 1, 2

Trulicity (Dulaglutide) - Preferred Option

Trulicity is specifically recommended by the American Diabetes Association for patients with type 2 diabetes and established cardiovascular disease (including stroke and heart disease) to reduce major adverse cardiovascular events. 1, 2

Evidence Supporting Use:

• The REWIND trial demonstrated that dulaglutide reduced the composite endpoint of non-fatal myocardial infarction, non-fatal stroke, or cardiovascular death (HR 0.88,95% CI 0.79-0.99; p=0.026) over 5.4 years of follow-up 3
• Dulaglutide specifically reduced ischemic stroke by 24% (HR 0.76,95% CI 0.62-0.94; p=0.010) and disabling stroke by 26% (HR 0.74,95% CI 0.56-0.99; p=0.042) 4
• The medication is safe in patients with prior heart failure, showing no increased risk of heart failure hospitalization 5
• ADA/EASD guidelines recommend GLP-1 receptor agonists like dulaglutide for patients with established cardiovascular disease or high-risk indicators including age ≥55 years, coronary/carotid stenosis, or left ventricular hypertrophy 2

Hypertension Considerations:

• No contraindication exists for dulaglutide use in hypertensive patients 1
• Patients should continue standard antihypertensive therapy with ACE inhibitors or ARBs as first-line agents for diabetes with hypertension 1

Januvia (Sitagliptin) - Safe but Less Preferred

Sitagliptin has no absolute contraindications in patients with HTN, diabetes, stroke, and heart disease, but it lacks the cardiovascular benefits demonstrated with Trulicity. 6

Important Caveats:

• One observational study in diabetic patients with chronic kidney disease after acute MI showed sitagliptin was associated with increased risks of recurrent MI (HR 1.73,95% CI 1.15-2.58; p=0.008) and need for percutaneous coronary revascularization (HR 1.43,95% CI 1.04-1.95; p=0.026) 7
• However, sitagliptin showed no increased risk of cardiovascular death, ischemic stroke, or heart failure hospitalization in this high-risk population 7
• Sitagliptin is well-tolerated with minimal side effects (primarily gastrointestinal complaints up to 16%) and does not cause significant hypoglycemia or weight gain 6

Dose Adjustment Required:

• Reduce dose to 25-50 mg once daily in patients with moderate-to-severe renal impairment, which is common in patients with longstanding diabetes, hypertension, and cardiovascular disease 6

Clinical Algorithm for Selection:

For patients with established cardiovascular disease (stroke, heart disease):

1. First choice: Trulicity (dulaglutide) - provides cardiovascular and stroke risk reduction 1, 3, 4
2. Consider Januvia (sitagliptin) only if GLP-1 receptor agonists are not tolerated or contraindicated 6

Concurrent management requirements:

• Continue ACE inhibitor or ARB for hypertension management (not both simultaneously) 1
• Target blood pressure <140/90 mm Hg 1
• Add statin therapy for cardiovascular risk reduction 1
• Consider adding SGLT2 inhibitor for additional cardiovascular and renal protection 1

Common Pitfalls to Avoid:

• Do not withhold Trulicity due to concerns about heart failure - the REWIND trial showed no increased risk of heart failure hospitalization 5
• Do not assume sitagliptin provides cardiovascular protection - it is neutral on cardiovascular outcomes, unlike Trulicity 7
• Do not forget to adjust sitagliptin dosing in patients with renal impairment, which is highly prevalent in this population 6
• Do not use ACE inhibitors and ARBs together - combination therapy increases adverse events without additional benefit 1