SGLT2 Inhibitors and GLP-1 Receptor Agonists in Clinical Practice

Introduction to SGLT2 Inhibitors

The American College of Cardiology recommends SGLT2 inhibitors, including empagliflozin, canagliflozin, and dapagliflozin, for their proven cardiovascular and renal benefits, with specific dosing based on indication and renal function 1, 2
The American College of Cardiology suggests that both 10 mg and 25 mg doses of empagliflozin showed similar cardiovascular benefits in the EMPA-REG OUTCOME trial 1

For patients with eGFR ≥45 mL/min/1.73 m², no dose adjustment is required for empagliflozin, according to the American College of Cardiology 1, 2
For patients with eGFR <45 mL/min/1.73 m², the American College of Cardiology recommends not initiating empagliflozin and discontinuing it if eGFR persistently falls below 45 mL/min/1.73 m² 1, 2
The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines recommend initiating dapagliflozin at an eGFR ≥20 mL/min/1.73 m² for CKD protection 4, 5

The American Diabetes Association recommends GLP-1 receptor agonists, including liraglutide, semaglutide, dulaglutide, and exenatide extended-release, for their proven cardiovascular benefits, with dosing varying by agent and formulation 4, 7, 6
The American College of Cardiology suggests that liraglutide reduced CV death by 22% in the LEADER trial 6
The American College of Cardiology recommends semaglutide for its cardiovascular benefit, reducing 3-point MACE by 26% in the SUSTAIN-6 trial 6

For patients with established ASCVD, the American Diabetes Association prefers GLP-1 receptor agonists, such as liraglutide, semaglutide, or dulaglutide, for maximum MACE reduction 7, 8
For patients with type 2 diabetes and CKD (eGFR 25-60 or albuminuria ≥200 mg/g), the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines prioritize SGLT2 inhibitors as first-line for kidney disease progression prevention, and GLP-1 receptor agonists if SGLT2 inhibitors are contraindicated or not tolerated 4, 5

The American College of Cardiology recommends prioritizing GLP-1 receptor agonists for type 2 diabetes with established ASCVD, and SGLT2 inhibitors for type 2 diabetes with heart failure (EF <45%) or CKD (eGFR 25-60 or albuminuria ≥200 mg/g) 7, 8, 4, 5
The American Diabetes Association suggests considering combination therapy with both SGLT2 inhibitors and GLP-1 receptor agonists for complementary mechanisms and enhanced efficacy in high-risk patients 7, 8