Interactive diabetes case 16: A 61-year-old patient with uncontrolled type 2 diabetes on two oral agents – A3

ANSWER — Incorrect.

Sitagliptin was the first of a class of agents marketed for the treatment of diabetes, the dipeptidyl peptidase 4 (DPP-4) inhibitors. Agents in this class inhibit the breakdown of endogenous glucagon-like peptide 1 (GLP-1) and other incretins. Thus, their biological effects are similar, but not identical, to those of GLP-1 agonists. (See "Dipeptidyl peptidase 4 (DPP-4) inhibitors for the treatment of type 2 diabetes mellitus", section on 'Patient selection'.)

Like the GLP-1 receptor agonists, DPP-4 inhibitors are indicated for patients with type 2 diabetes but not those with type 1 diabetes.

DPP-4 inhibitors are given orally. For all DDP-4 inhibitors except linagliptin, a dose adjustment is required in patients with impaired kidney function (table 1). They are relatively expensive. In postmarketing reports, DPP-4 inhibitors have been associated with hypersensitivity reactions including anaphylaxis, angioedema, and blistering skin conditions, including Stevens-Johnson syndrome. They have also been associated with severe joint pains.

The US Food and Drug Administration (FDA) issued an alert about a possible association of incretin-based drugs such as sitagliptin (and exenatide) with acute pancreatitis based upon a review of 30 postmarketing reports, in some of which a causal relationship between these agents and acute pancreatitis was suspected. The FDA and the European Medicines Agency now agree that there is insufficient evidence to confirm an increased risk of pancreatitis or pancreatic cancer with the use of GLP-1-based therapies [1]. Pancreatitis continues to be considered a risk associated with these drugs. Concerns remain, and monitoring for and reporting of pancreatic adverse effects continues.

Sitagliptin has not been shown to be superior to any other single pharmacologic agent in direct comparison. The addition of sitagliptin to a single oral agent has not been shown to be superior to other two-agent combinations, such as metformin and a sulfonylurea.

Because of its relatively high cost and weak therapeutic effect, sitagliptin is typically not recommended for routine use. It may have an occasional role as a third oral agent in patients with a modest elevation of the glycated hemoglobin (A1C) level when maximum tolerated doses of metformin and another agent have not achieved glycemic goals.

Return to the beginning to try again. (See "Interactive diabetes case 16: A 61-year-old patient with uncontrolled type 2 diabetes on two oral agents".)