What are the considerations for switching from teneligliptin (Dipeptidyl peptidase-4 (DPP-4) inhibitor) to vildagliptin (DPP-4 inhibitor) in a patient with Impaired glycemic control?

Switching from Teneligliptin to Vildagliptin in Impaired Glycemic Control

Direct Recommendation

You should generally avoid switching from teneligliptin to vildagliptin, as current guidelines recommend against using DPP-4 inhibitors altogether when glycemic control is inadequate—instead, prioritize adding an SGLT-2 inhibitor or GLP-1 receptor agonist to metformin. 1

Guideline-Based Treatment Hierarchy

First-Line Approach for Inadequate Control

• The American College of Physicians strongly recommends adding an SGLT-2 inhibitor or GLP-1 agonist to metformin when glycemic control is inadequate, rather than switching between DPP-4 inhibitors 1
• DPP-4 inhibitors are explicitly not recommended for reducing morbidity and all-cause mortality in patients with inadequate glycemic control 1
• SGLT-2 inhibitors reduce all-cause mortality, major adverse cardiovascular events, chronic kidney disease progression, and heart failure hospitalization 1
• GLP-1 agonists reduce all-cause mortality, major adverse cardiovascular events, and stroke 1

When DPP-4 Inhibitors May Be Considered

• DPP-4 inhibitors (sitagliptin and linagliptin specifically) have a neutral effect on heart failure risk and may be considered only in limited circumstances 1
• Saxagliptin is contraindicated in patients with type 2 diabetes and high risk of heart failure 1
• DPP-4 inhibitors may be appropriate in hospitalized elderly patients with mild to moderate hyperglycemia when combined with basal insulin 1

Specific Considerations for Teneligliptin vs. Vildagliptin

Comparative Efficacy Evidence

• Research shows teneligliptin 20 mg once daily may be more potent than vildagliptin 50 mg once daily in hemodialysis patients with end-stage renal disease 2
• In patients with advanced diabetic kidney disease, switching from linagliptin to teneligliptin showed no improvement in glycemic control, urinary protein excretion, or renal function decline 3
• Both agents are effective in hemodialysis patients, but teneligliptin requires no dose adjustment while vildagliptin requires reduction to 50 mg daily in ESRD 4, 2, 5

Renal Function Considerations

• Vildagliptin requires dose reduction to 50 mg once daily when eGFR <30 mL/min/1.73 m² 4
• Teneligliptin requires no dose adjustment in renal impairment due to dual hepatic and renal elimination 4, 2, 6
• If your patient has renal impairment, teneligliptin has a dosing advantage, but this should not override the guideline recommendation to use SGLT-2 inhibitors or GLP-1 agonists instead 1

Clinical Algorithm for Decision-Making

Step 1: Assess Cardiovascular and Renal Comorbidities

• If established cardiovascular disease or high CV risk exists: Add SGLT-2 inhibitor (empagliflozin, canagliflozin, or dapagliflozin) 1
• If chronic kidney disease present: Prioritize SGLT-2 inhibitor to reduce progression 1
• If heart failure present: Add SGLT-2 inhibitor; avoid saxagliptin 1
• If stroke risk or weight loss is priority: Add GLP-1 agonist (liraglutide, semaglutide, or dulaglutide) 1

Step 2: If DPP-4 Inhibitor Must Be Used

• Only consider if SGLT-2 inhibitors and GLP-1 agonists are contraindicated or not tolerated 1
• In ESRD (eGFR <30 mL/min/1.73 m²): Teneligliptin 20 mg daily requires no adjustment; vildagliptin requires reduction to 50 mg daily 4, 2
• Linagliptin is the only DPP-4 inhibitor requiring no dose adjustment in any stage of renal disease 4

Step 3: Avoid Common Pitfalls

• Do not delay treatment intensification—switching between equivalent DPP-4 inhibitors wastes time when superior options exist 1
• Reduce or discontinue sulfonylureas or long-acting insulin when adding SGLT-2 inhibitors or GLP-1 agonists to prevent severe hypoglycemia 1
• Avoid saxagliptin entirely in patients with heart failure risk 1

Safety Considerations

Cardiovascular Safety Profile

• Vildagliptin demonstrated improved glycemic control in the VERIFY trial when used as initial combination therapy with metformin, showing slower decline in glycemic control 1
• However, cardiovascular outcome trials for DPP-4 inhibitors showed safety but no cardiovascular benefit (saxagliptin, alogliptin, sitagliptin) 1
• Saxagliptin and alogliptin showed imbalances in heart failure hospitalization 1

Adverse Effects

• Both teneligliptin and vildagliptin are well-tolerated with minimal hypoglycemia risk when used as monotherapy 2, 5, 6
• Teneligliptin may cause QT prolongation—exercise caution in susceptible patients 6
• Rare pancreatitis and musculoskeletal side effects reported with DPP-4 inhibitor class 1

Bottom Line

Rather than switching from teneligliptin to vildagliptin, reassess your patient's treatment strategy entirely. The evidence strongly supports adding an SGLT-2 inhibitor or GLP-1 agonist to metformin for patients with inadequate glycemic control, as these agents reduce mortality and major cardiovascular events—outcomes that DPP-4 inhibitors do not improve 1. If you must use a DPP-4 inhibitor due to specific contraindications, teneligliptin may actually be preferable to vildagliptin in patients with renal impairment due to its lack of required dose adjustment 4, 2.