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SGLT2i vs DPP-4i CV Evidence — EECC MCQ

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ModerateCardiac PharmacologySGLT2i vs DPP-4i CV EvidenceEECC

A 60-year-old man with stable CAD and diabetes is on metformin and linagliptin (DPP-4 inhibitor). His cardiologist recommends switching from linagliptin to empagliflozin. Why is this switch recommended for cardiovascular benefit?

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Correct answer: E — SGLT2 inhibitors (empagliflozin) have proven cardiovascular outcome benefit in diabetic patients with established ASCVD (EMPA-REG OUTCOME: 38% reduction in CV death), whereas DPP-4 inhibitors (linagliptin, sitagliptin) have shown cardiovascular safety but NOT superiority over placebo

The hierarchy of glucose-lowering agents for cardiovascular benefit in T2DM is now established: (1) SGLT2 inhibitors: EMPA-REG OUTCOME (empagliflozin — 38% CV death reduction), CANVAS (canagliflozin), DECLARE (dapagliflozin) — Class I recommendation for T2DM with established ASCVD or high CV risk; (2) GLP-1 RAs: LEADER (liraglutide), SUSTAIN-6 (semaglutide) — significant MACE reduction, Class I; (3) DPP-4 inhibitors: CAROLINA (linagliptin), TECOS (sitagliptin), EXAMINE (alogliptin) — CV neutral (no benefit, no harm) — saxagliptin (SAVOR-TIMI 53) increased HF hospitalisation; (4) Metformin: UKPDS historical evidence but no contemporary CV outcome trial. The ESC/EASD Diabetes Guidelines recommend prioritising SGLT2i and/or GLP-1 RA over DPP-4i in T2DM patients with ASCVD, HF, or CKD.

Reference: ESC/EASD Diabetes Guidelines; EMPA-REG OUTCOME