SGLT2 Inhibitors and GLP-1 Receptor Agonists in Type 2 Diabetes

Introduction to SGLT2 Inhibitors and GLP-1 Receptor Agonists

The American Diabetes Association recommends using GLP-1 receptor agonists for patients with type 2 diabetes and established atherosclerotic cardiovascular disease, while SGLT2 inhibitors are preferred for patients with heart failure with reduced ejection fraction or chronic kidney disease 1, 2, 3

The American College of Cardiology recommends choosing GLP-1 receptor agonists when established atherosclerotic cardiovascular disease is the dominant problem, with a high strength of evidence 2, 3
The European Association for the Study of Diabetes suggests choosing GLP-1 receptor agonists for high cardiovascular risk without established disease, with a moderate strength of evidence 2, 3
The American Heart Association recommends choosing GLP-1 receptor agonists for obesity where weight loss is a priority, with a low strength of evidence 4

The American College of Cardiology recommends choosing SGLT2 inhibitors when heart failure with reduced ejection fraction is present, with a high strength of evidence 2, 3, 4
The European Association for the Study of Diabetes suggests choosing SGLT2 inhibitors for chronic kidney disease with eGFR 30-60 mL/min/1.73 m², with a moderate strength of evidence 2, 3, 4

Semaglutide, liraglutide, and dulaglutide are the only GLP-1 receptor agonists with proven MACE reduction, according to the American Diabetes Association, with a high strength of evidence 5
These agents reduce MACE by 12-26%, with a moderate strength of evidence 5
They also reduce HbA1c by 0.8-1.5%, with a low strength of evidence 5

SGLT2 inhibitors reduce hospitalization for heart failure, cardiovascular death, and progression of chronic kidney disease, according to the American Heart Association, with a high strength of evidence 1
They also reduce cardiovascular death, hospitalization for heart failure, and urgent heart failure visits, with a moderate strength of evidence 1

The American College of Cardiology recommends using both an SGLT2 inhibitor and a GLP-1 receptor agonist for maximal cardiorenal protection in patients with both established atherosclerotic cardiovascular disease and chronic kidney disease, with a high strength of evidence 3
The European Association for the Study of Diabetes suggests prioritizing GLP-1 receptor agonists over insulin when additional glucose-lowering is needed, with a moderate strength of evidence 4

The American Diabetes Association recommends stratifying patients into very high risk, high risk, moderate risk, and lower risk categories for treatment decisions, with a high strength of evidence 2, 3
Very high risk patients should be treated with SGLT2 inhibitors, with a high strength of evidence 3
High risk patients may be treated with either SGLT2 inhibitors or GLP-1 receptor agonists, with a moderate strength of evidence 2, 3