Jeffrey Berger, MD: When to use GLP1 Agonists or SGLT2 Inhibitors


How and when do you decide whether to prescribe a patient GLP1 agonists or SGLT2 inhibitors?

As more Americans are diagnosed with Type 2 Diabetes every year, more and more physicians are being tasked with helping patients manage this disease. For some, that means receiving a prescription for either glucagon-like peptide-1 (GLP1) agonists or sodium/glucose cotransporter 2 (SGLT2) inhibitors.

Jeffrey Berger, MD, associate professor of medicine and surgery at NYU Langone Health, sat down with MD Magazine® to discuss how he determines which is more appropriate for his patients and whether someone should ever prescribe both.

MD Mag: How do you determine whether to prescribe GLP1 agonists or SGLT2 inhibitors to a patient?

Berger: So, I think we are in a new era of taking care of patients with diabetes. For a long time, the FDA has mandated that when a new drug comes out you want to make sure that it not only improves glucose control but that it also is not potentially harmful, in terms of cardiovascular risk. For the first time, in a very long time, we have new drugs that not only are they not harmful but they are actually helpful in preventing cardiovascular events. So, we have GLP1 agonists and they were shown to reduce the composite of cardiovascular events and we have SGLT2 inhibitors, which too were shown to reduce cardiovascular events in addition to improving glucose control. I think when you look at the original studies and you look at the original data, I think that there are important differences in how the drugs prevent cardiovascular events, that should drive when they are being used.

So, for example, the GLP1 agonists when you look at what part of the composite of cardiovascular events they reduce it appears to be more, in terms of preventing atherosclerotic cardiovascular events, like heart attacks. When you look at the SGLT2 inhibitors their data is fantastic, very impressive but, when you look at how they reduce cardiovascular events it is really driven by their reduction in cardiovascular death and their effect on heart failure endpoints.

So, to me it appears that maybe these drugs should be targeted to individuals at the highest risk for each of those components. So, for example, somebody who is at risk for heart failure as an endpoint or perhaps an arrhythmic type of death perhaps an SGLT2 inhibitor would be the first approach. Somebody who may be at high risk for an atherosclerotic endpoint, perhaps a GLP1 but, I do believe that there are patients and there is a rationale for certain patients to be treated with both compounds. I think we are in a new phase, a new era, where we have this option of really targeting not just glucose control but also cardiovascular events. So as a practitioner, who takes care of patients with diabetes I think this is a really exciting time.

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