Considering the new T2D agents

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He Ako Hiringa
17 August 2021
Bulletin #6

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Considering the new T2D agents

In 2021, two new second-line type 2 diabetes medicines are funded for patients with diabetic kidney disease, known cardiovascular disease or a five-year CVD risk of ≥15 per cent. Criteria also cover Māori or Pacific peoples and early onset T2D.1

But is empagliflozin or dulaglutide better suited to your patient?

Both agents reduce CVD mortality and slow progression of renal disease, independent of effects on glycaemic control,2 although dulaglutide is yet to be shown to prevent dialysis or renal death. Empagliflozin, in particular, reduces hospitalisations and deaths due to heart failure. If HF or diabetic kidney disease is predominant, empagliflozin is preferable; if cerebrovascular disease predominates, dulaglutide is likely favoured.3

Unlike empagliflozin, some data suggest dulaglutide may be effective in primary prevention of CVD.4 Neither medicine has yet been shown to prevent diabetic kidney disease.2

Both agents improve glycaemic control and blood pressure. Dulaglutide likely has a greater effect on reducing HbA1c and weight than empagliflozin, but less effect on BP.2,3

Other influences matter

Always consider whether potential adverse effects outweigh benefits, particularly in frail patients or those with short life expectancy.

People with personal or family history of medullary thyroid cancer cannot be prescribed dulaglutide nor is it recommended in people with severe gastrointestinal disease or previous pancreatitis.5,6

Empagliflozin must be used with caution in people at high risk of diabetic ketoacidosis; for those with previous history of DKA, specialist approval is recommended.7 Caution is needed if there is a high risk of volume depletion as empagliflozin promotes glycosuria and associated osmotic diuresis.2,7

If your patient has previous severe or recurrent genitourinary infections, or is likely to be on a low carbohydrate diet and/or have significant alcohol intake, empagliflozin is not for them.3

Neither agent should be used in pregnancy, breastfeeding or in children <18 without specialist approval. Finally, dulaglutide can be used safely in patients with estimated glomerular filtration rates (eGFR) between 15 and 30mL/min, but empagliflozin cannot.6,7

Empagliflozin or dulaglutide?

When initiating either empagliflozin or dulaglutide, the newly funded second-line type 2 diabetes agents,1 choice is based primarily on predominant comorbidities, clinical features and tolerability.

But patient preference is an additional factor, with administration route influential. Dulaglutide, a subcutaneous injection, is self-administered weekly. Empagliflozin is a daily oral tablet; combination empagliflozin/metformin is available, which may aid adherence.3

Switching from empagliflozin to dulaglutide is straightforward, but vildagliptin, if used, must be stopped.3 Remember, empagliflozin and dulaglutide can be used together, but one will need self-funding.

HAH Bulletin references

  1. Pharmac. Decision to fund two new medicines for type 2 diabetes - Amended with Q&A. Jan 2021.
  2. He Ako Hiringa. What’s new with type 2 diabetes care in 2021? Use of SGLT2 inhibitors and GLP-1 agonists.
  3. New Zealand Society for the Study of Diabetes. Type 2 diabetes management guidelines: Non-insulin medications. Accessed July 2021.
  4. Gerstein HC, Colhoun HM, Dagenais GR. Dulaglutide and cardiovascular outcomes in type 2 diabetes (REWIND): a double-blind, randomised placebo-controlled trial. Lancet 2019;394(10193)121–30.
  5. BPACnz. New diabetes medicines funded: empagliflozin and dulaglutide. June 2021.
  6. NPS MedicineWise. Trulicity: Dulaglutide. Jul 2020.
  7. Medsafe. Jardiance (empagliflozin) data sheet. Dec 2019.

Content updates

14 July 2022: Updated after full review (May 2022) by Dr Ryan Paul, academic endocrinologist at Waikato District Health Board and at the University of Waikato.