6.1.2.3 Dipeptidyl peptidase-4 inhibitors (DPP-4 inhibitors)

ChoiceDrugDosage
First choicesAlogliptin tablets 6.25mg, 12.5mg,25mgDose: 25mg once daily Reduce dose to: 12.5mg once daily if eGFR 30-50mL/ min 6.25mg once daily if eGFR <30mL/min
Or
Sitagliptin tablets 25mg, 50mg, 100mgDose: 100mg once daily Reduce dose to: 50mg once daily if eGFR 30-50mL/min 25mg once daily if eGFR <30mL/min or End Stage Renal Disease
2nd choiceLinagliptin tablets 5mgDose:
5mg once daily
(no dose reduction needed in renal impairment)

Prescribing Notes

  • DPP-4 inhibitors have been shown to have a modest impact on HbA1c with mean reduction of 0.6-0.8%, but there is no data on morbidity, mortality or long-term adverse effects. Review after 6 months to assess benefit.
  • The DPP-4 inhibitors differ in terms of their licensed indications/combinations.
  • Some factors to consider when choosing between DPP-4 inhibitors:
    • alogliptin is the most cost-effective option. Regarding cardiovascular safety, it has published outcome data demonstrating non-inferiority to placebo in patients with acute coronary syndrome
    • sitagliptin has the greatest clinical experience and widest range of licensed indications and has demonstrated cardiovascular safety in outcome trials
    • linagliptin does not require dose reduction in renal impairment. Cardiovascular safety outcome data is awaited (expected 2019)
  • Prescribe as per NICE Guideline NG28 recommendations. See also NICE Algorithm for blood glucose lowering therapy in adults with type 2 diabetes.
  • A small increased risk of acute pancreatitis has been identified for all licensed DPP-4 inhibitors. Patients should be informed of the characteristic symptoms of acute pancreatitis – persistent, severe abdominal pain (sometimes radiating to the back) – and encouraged to tell their healthcare provider if they have such symptoms. Refer to MHRA advice for full details.