Can a patient with type 2 diabetes (T2D) and impaired renal function be switched from saxagliptin to Januvia (sitagliptin)?

Switching from Saxagliptin to Januvia (Sitagliptin)

Yes, a patient with type 2 diabetes and impaired renal function can be switched from saxagliptin to sitagliptin (Januvia), and this switch is particularly advisable if the patient has heart failure risk or established cardiac disease, as saxagliptin carries a 27% increased risk of heart failure hospitalization. 1

Primary Rationale for Switching

Cardiovascular Safety Considerations:

• Saxagliptin should be avoided in patients with heart failure risk or established heart failure, as demonstrated by the SAVOR-TIMI 53 trial showing a 27% relative increase in heart failure hospitalization (HR 1.27,95% CI 1.07-1.51). 1
• Sitagliptin has demonstrated cardiovascular safety with a neutral effect on heart failure risk (HR 1.00,95% CI 0.83-1.20) in the TECOS trial, making it a safer alternative within the DPP-4 inhibitor class. 1
• Both saxagliptin and alogliptin have been associated with increased risk of heart failure hospitalization, requiring caution in patients with cardiac disease. 1

Renal Function-Based Dosing Algorithm

For patients with eGFR ≥45 mL/min/1.73 m²:

• Switch to sitagliptin 100 mg once daily without dose adjustment. 1

For patients with eGFR 30-44 mL/min/1.73 m² (moderate renal impairment):

• Switch to sitagliptin 50 mg once daily. 1, 2

For patients with eGFR <30 mL/min/1.73 m² (severe renal impairment):

• Switch to sitagliptin 25 mg once daily. 1, 2

For patients with any degree of renal impairment who need simplicity:

• Consider linagliptin 5 mg daily instead, as it requires no dose adjustment regardless of renal function status. 1

Equivalency and Efficacy

• Both saxagliptin and sitagliptin are DPP-4 inhibitors with similar glucose-lowering efficacy, reducing HbA1c by approximately 0.4% to 0.9%. 1
• Both medications work through the same mechanism—increasing endogenous GLP-1 levels by reducing its deactivation, enhancing insulin secretion and inhibiting glucagon secretion in a glucose-dependent manner. 1
• The switch can be made directly without a washout period, as both medications have similar pharmacodynamic profiles. 3, 4

Important Clinical Caveats

Hypoglycemia Risk:

• Both agents have minimal hypoglycemia risk when used as monotherapy, but risk increases approximately 50% when combined with sulfonylureas. 1
• Monitor closely if the patient is on concurrent insulin, sulfonylureas, or glinides. 1

Renal Function Monitoring:

• With sitagliptin, regular monitoring of renal function is needed to adjust dosing if kidney function declines. 1
• Saxagliptin requires dose reduction to maximum 2.5 mg daily when eGFR ≤45 mL/min/1.73 m². 1

When NOT to Use Either DPP-4 Inhibitor:

• For patients with established atherosclerotic cardiovascular disease, heart failure, or chronic kidney disease with albuminuria, SGLT2 inhibitors or GLP-1 receptor agonists are strongly preferred over any DPP-4 inhibitor due to proven cardiovascular and renal benefits. 1
• Neither sitagliptin nor saxagliptin has demonstrated cardiovascular benefit—only cardiovascular safety. 1

Practical Switching Protocol

1. Discontinue saxagliptin on day 1
2. Start sitagliptin on day 1 at the appropriate dose based on current eGFR
3. Monitor blood glucose for the first week to ensure continued glycemic control
4. Reassess HbA1c within 3 months to confirm therapeutic efficacy 1
5. Monitor for signs/symptoms of heart failure if the patient has cardiac risk factors 1