18.104.22.168 Dipeptidyl peptidase-4 inhibitors (DPP-4 inhibitors)
|First choices||Alogliptin tablets 6.25mg, 12.5mg,25mg||Dose: 25mg once daily Reduce dose to: 12.5mg once daily if eGFR 30-50mL/ min 6.25mg once daily if eGFR <30mL/min|
|Sitagliptin tablets 25mg, 50mg, 100mg||Dose: 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 choice||Linagliptin tablets 5mg||Dose: |
5mg once daily
(no dose reduction needed in renal impairment)
- 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.