Sam Engel, MD: Sitagliptin versus Dapagliflozin in Older Patients

A recent study has found that sitagliptin is more efficacious and safer treatment than dapagliflozin for patients of type 2 diabetes over the age of 65.

Investigators presented the post hoc analysis of a 24-week randomized, double-blind clinical trial comparing once-daily sitagliptin 100 mg with once-daily dapagliflozin 10 mg the American Diabetes Association (ADA) 2019 Scientific Sessions in San Francisco, CA.

The primary endpoint was change in A1C at week 24. Investigators noted that treatment groups were well-balanced at baseline. At week 24, the least squares mean reduction from baseline was greater with sitagliptin than with dapagliflozin. In the sitagliptin group, 41% of participants achieved A1C of less than 7% compared to 28% of the dapagliflozin group.

Additionally, the sitagliptin group saw greater reduction in post-prandial endpoints and the dapagliflozin had greater reduction in fasting blood glucose. Investigators observed fewer drug-related adverse events with sitatgliptin than dapagliflozin but adverse event profiles were otherwise similar.

Sam Engel, MD, vice president of clinical research in diabetes at Merck, sat down with MD Magazine® at ADA 2019 to discuss the findings of the post hoc analysis and what the results mean for health care providers.

MD Mag: What did you find when comparing sitagliptin to dapagliflozin in t2d patients 65 and older?

Engel: You know, with all the choices of anti-hyperglycemic medications for people with type 2 diabetes, it's important, of course, to be able to individualize therapy and in particular to look at patient profile and see whether or not certain medications are more effective, less effective, safe in these specific populations. In particular, we've been focusing on people over the age of 65. There are number of reasons that we do that.

First, people over 65 tend to have other medical conditions, they may be taking other medications, and, importantly, a large proportion of them close to 50% have mild renal insufficiency or stage 2 chronic kidney disease. So, we performed a study, which was actually published and presented here at ADA last year, where we looked at sitagliptin compared to dapagliflozin, an sglt2 inhibitor, in patients who had mild renal insufficiency. In that study, the primary analysis showed that sitagliptin was, both, non-inferior and superior to dapagliflozin and had safety and tolerability profile which was very comparable. In this analysis, which we've presented here at ADA, we've specifically looked at the population in that study who were over 65 years of age. They comprised about two-thirds of the population. So, it's very robust study to look at this issue and in this post-hoc analysis what we saw in the older population was a very similar efficacy profile to what was seen in the primary study. Sitagliptin and dapagliflozin — both were effective at lowering a1c; numerically sitagliption provided a little bit more a1c lowering than dapagliflozin. The safety and tolerability profiles were comparable.

There was a slightly higher rate of drug related adverse experiences with dapagliflozin but that was primarily driven by general mycotic infections, which is common with the class. So, what are the implications of the study? I think, clearly as the population is getting older and the prevalence of diabetes is higher in people as they get older, it's important to have studies that specifically focus on the profile for patients and so, we think this post-hoc analysis adds to the database regarding the choices of anti hyperglycemics for older individuals.