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Choosing GLP-1 RAs versus SGLT2i: Adults with type 2 diabetes taking metformin with A1C above goal but ≤9% and eGFR >15 mL/min/1.73 m2

Choosing GLP-1 RAs versus SGLT2i: Adults with type 2 diabetes taking metformin with A1C above goal but ≤9% and eGFR >15 mL/min/1.73 m2
GLP1-RAs or SGLT2i are preferred in the setting of ASCVD, including HF (SGLT2i), and prevalent kidney disease (eGFR <60 mL/min/1.73 m2 or albuminuria). Exclude contraindications and precautions prior to use (inset box). Refer to UpToDate content for additional information about GLP-1 RAs and SGLT2i.

GLP-1 RA: glucagon-like protein 1 receptor agonist; SGLT2i: sodium-glucose co-transporter 2 inhibitor; A1C: glycated hemoglobin (hemoglobin A1C); eGFR: estimated glomerular filtration rate; MEN: multiple endocrine neoplasia; UTI: urinary tract infection; DKA: diabetic ketoacidosis; ASCVD: atherosclerotic cardiovascular disease; CKD: chronic kidney disease; HF: heart failure.

* The eGFR threshold for use of SGLT2i is evolving. Some experts prescribe SGLT2i for patients with CKD with an eGFR ≥20 mL/min/1.73 m2. SGLT2i have little glycemic efficacy with eGFRs in this range, and an alternative agent is needed to improve glycemia.

¶ GLP-1 RAs with evidence of ASCVD and CKD benefit: dulaglutide, liraglutide, and subcutaneous semaglutide.

Δ All SGLT2i have shown evidence of benefit for HF and CKD. SGLT2i have decreasing glycemic efficacy as eGFR declines, particularly with eGFR <45 mL/min/1.73 m2, and in this setting, an additional agent may be necessary to achieve glycemic goals.

◊ SGLT2i with evidence of ASCVD benefit: canagliflozin, dapagliflozin, and empagliflozin.
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