Use of Generic DPP4i + SGLT2i FDCs by Indian Physicians - The DiSi Survey

Results:

• Total 185 physicians from multiple states of India completed the survey
• In Indian Clinical Practice, there is a significant burden of patients with T2DM who present with high baseline HbA1c (newly diagnosed treatment naive or despite metformin monotherapy)
• 48% physicians reported that more than 40% of their newly diagnosed, treatment-naive patients present with a baseline HbA1c >8%
• 52% physicians reported that, more than 40% of patients present with HbA1c >8.5% despite metformin monotherapy

• Generic DPP4i/SGLT2i FDCs were preferred in these patients also considering their extra-glycemic benefits.
• 60.5% (n=112) respondents prescribe these FDCs due to all four clinical reasons namely:-
• CV benefits of SGLT2i are an added advantage in Indian population (since Indian patients often have clustering of multiple CV risk factors).
• Targets multiple pathways in ominous octet.
• FDCs promotes weight loss.
• Significantly lesser risk of hypoglycaemia compared to sulfonylurea (SU) based FDCs.

• From a glycemic control perspective, 65.9% of respondents preferred DPP4i–SGLT2i FDCs for below 3 scenarios, namely:
• Treatment-naive patients with contraindication/ intolerance to metformin and HbA1c >8%.
• Uncontrolled on metformin monotherapy with HbA1c >8.5%.
• As add-on to insulin.

• Unique Finding - Most physicians (85%) noted reduction in SGLT2i associated Genito-Urinary Tract Infections (GUTIs) with use of DPP4i/SGLT2i FDCs or concomitant administration of both agents.
• Further well designed studies may confirm this finding

• Amongst the DPP4i/SGLT2i FDCs available in India, most physicians preferred Sitagliptin/Dapagliflozin as FDC of choice. Sita-Dapa was the most preferred FDC (36.2% respondents) of respondents (n=67).

Takeaways:

• Indian phenotype is associated with clustering of CV risk factors like HTN, dyslipidemia, and abdominal obesity which lead to early atherosclerotic cardiovascular disease compared to Caucasian populations.
• Hence, management of T2DM in India warrants early consideration of therapies that confer CV protection (e.g., SGLT2i) at the time of diagnosis itself.
• Studies have demonstrated that in global reference populations, patients with diabetes have already lost approximately 50% of their β-cell mass at the time of diagnosis itself. Also South Asian phenotype has reduced baseline β-cell function vs population groups.
• This further underscores the need for considering agents that preserve β-cell function (e.g., DPP4is) early in the course of diabetes
• This pan-India survey also highlights that patients with T2DM often present with a high baseline HbA1c in the Indian physician’s clinic. SGLT2i-DPP4i FDCs satiate an important gap whereby current guidelines recommend initiating dual-combination therapy when target HbA1c is >1.5% compared to baseline HbA1c.

Reference: Saboo B, Prajapati C, Muralidharan P, et al. DiSi Survey: Use of Generic DPP4i–SGLT2i Fixed-dose Combinations in Indian Clinical Practice. J Assoc Physicians India 2024;72(12):22–24