Evergreen Talk Series: Use of SGLT2i and DPP4i combination in T2DM patients with a history of Genitourinary Tract Infections

Presenting the Evergreen Talk Series featuring Dr. Brij Mohan Makkar, a Senior Diabetologist and Obesity Specialist from Delhi, Dr Sameer I. Dani, an Interventional Cardiologist from Ahmedabad, and Dr. Tukaram Jamale, a Nephrologist and Kidney Transplant Physician who serves as the Head of the Department at KEM Hospital Mumbai. They provide their insights on the use of Linagliptin, Dapagliflozin, and Metformin for diabetic patients.

Bringing viewpoints from the different specialities of Diabetology, Cardiology and Nephrology they share their views about the Use of SGLT2i and DPP4i combination in T2DM patients with Genitourinary Tract Infections history.

Dr Brij Mohan Makkar: When you are combining gliptin and SGLT2i, the risk of genital UTI is lower. One reason possibly is the suppression of glucagon, which results in lower glucosuria. Other thing is that DPP4 is also the same enzyme as CD-26, and it is involved in immune regulation. DPP4 inhibitors actually enhance immune function to some extent.

Dr Sameer I Dani: When you combine DPP4i with SGLT2i, the risk of genitourinary tract infection is lower. We have enough evidence and trials confirming the addition of DPP4 inhibitor to SGLT2i in a sequential manner, or SGLT2 inhibitor to DPP4 in a sequential manner, versus both given together. We have seen that when the DPP4i linagliptin and dapagliflozin are combined and administered simultaneously or co-administered, the risk of genitourinary tract infection is lower compared to sequential administration. Linagliptin is safe and renal-safe, improving CV outcomes and decreases genito-urinary tract infections which I think is very relevant in clinical practice, and that is why fixed dose or a combination therapy simultaneously administered is very important.

Dr Tukaram Jamale: Uncontrolled diabetes, when that is the risk factor for such patients, usually presents with a history of multiple UTIs before initiating treatment with either linagliptin or dapagliflozin. So, in such patients, it may not be the absolute contraindication as these patients will benefit from good glycaemic control that can be offered by linagliptin and kidney protection by Dapagliflozin. But other type of urinary tract infections that develop after initiating SGLT2 inhibitors, that is very well described adverse effect of SGLT2 inhibitors and Dapagliflozin. So, they also need to be considered in the context of the severity of such infections. Isolated cystitis without upper urinary tract involvement, like pyelonephritis, will not be a contraindication, given the overwhelming benefits of these agents in protecting the heart and kidneys. One cannot rule out or one cannot exclude the possibility of these agents in such patients. So only when it's recurrent; recurrent, by definition, is more than three or four episodes in a year or any serious urinary tract infection like Urosepsis, upper urinary tract involvement in such patients, of course, one would be sceptical about initiating. In situations where careful monitoring is possible, initiation can be considered. And in the previous situations, with careful monitoring, definitely it can be.