Place in Therapy
Both the 2015 update to the ADA/European Association for the Study of Diabetes (EASD) position statement and the 2017 ADA diabetes care guidelines have classified SGLT2 inhibitors as second-line agents after metformin.[5,24] The ADA guidelines also state that empagliflozin should specifically be considered for patients with T2DM and established atherosclerotic CV disease to reduce CV and all-cause mortality (level of evidence B), but they include a cautionary warning about the uncertainty of a drug-class effect related to CV protection.
The American Association of Clinical Endocrinologists (AACE) and the American College of Endocrinology (ACE) also provided a consensus statement on the comprehensive T2DM-management algorithm, which discusses the efficacy and safety of SGLT2 inhibitors and their place in therapy. Unlike the ADA/EASD statement and the ADA guidelines, the 2017 AACE/ACE consensus statement suggests a hierarchy of antidiabetic drug usage. Of all available antidiabetic drugs, including oral and injectable agents, AACE/ACE placed SGLT2 inhibitors as third-line treatment after metformin and glucagon-like peptide-1 receptor agonists. Therefore, per the AACE/ACE guidelines, SGLT2 inhibitors are preferred to alternative antidiabetic drugs.
In addition to the recommendations of national guidelines, providers should carefully assess the additional benefits of SGLT2 inhibitors versus safety concerns and drug interactions (Table 3). Since SGLT2 inhibitors are relatively new and available as brand only, cost should also be considered.[5,24,25]
US Pharmacist. 2017;42(10):42-47. © 2017 Jobson Publishing