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Saxagliptin

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Saxagliptin, Onglyza

  • See Also
  1. DPP-4 Inhibitor
  2. Incretin Mimetic
  3. Type II Diabetes Medications
  4. Sitagliptin
  5. Linagliptin
  6. Alogliptin
  • Indications
  1. Type II Diabetes Mellitus
  2. Insulin deficiency and Insulin Resistance
    1. Adjunct to Glucophage, Sulfonylureas, Glitazones
  • Contraindications
  1. Type I Diabetes Mellitus
  2. Congestive Heart Failure
  3. Prior history of malignancy
    1. Due to increased risk of cancer invasion and metastases
  • Mechanism
  1. See DPP-4 Inhibitor
  2. Dipeptidyl Peptidase-4 (DPP-4) is an enzyme that degrades the Incretins GLP-1 and GLP-2
    1. Incretins (GIP and GLP1) are normally released from GI Tract (enteroendocrine cells) following meals
    2. Incretins increase Glucose dependent Insulin secretion, and inhibit Glucagon secretion
  3. DPP4 Inhibitor Activity
    1. DPP-4 Inhibitors block Incretin degradation
      1. Allows accumulation of GLP-1 by 2-3 fold
    2. Activate Glucose-Dependent Insulinotropic Polypeptides
      1. Stimulates beta cells to secrete Insulin
      2. Lowers Blood Sugar, but low risk of Hypoglycemia
  4. Differs from GLP1 Agonists
    1. Weight neutral
    2. No Nausea
  • Precautions
  1. DPP-4 Inhibitors are less than half as effective as lower cost medications (e.g. Metformin, Sulfonylureas)
  2. No longterm evidence of improved outcomes
  3. Decrease dose in renal Impairment
  4. May consider for those close to goal AND
    1. Already either on other Oral Hypoglycemics or in whom they are contraindicated (e.g. Chronic Kidney Disease)
  • Medications
  1. Saxagliptin (Onglyza) tablets: 2.5, 5 mg
  • Dosing
  1. Saxagliptin 2.5 to 5 mg/day
    1. Adjust for renal Impairment
  • Adverse Effects
  1. Unless otherwise noted, adverse effects are for DPP-4 Inhibitor in general
  2. Acute Pancreatitis
    1. Incidence may be as high as 1 in 50 for two years
    2. Singh (2013) JAMA Intern Med 173(7):534-9 [PubMed]
  3. Serious Allergic Reaction (Sitagliptin)
    1. Anaphylaxis
    2. Angioedema
  4. Hepatotoxicity (Alogliptin, Vlidagliptin)
  5. Headache
  6. Bullous Pemphigoid
  7. Congestive Heart Failure exacerbation
    1. Risk of hospitalized CHF exacerbation: 1 in 150 patients/2 years using Saxigliptin or Alogliptin
    2. Higher risk with pre-existing CHF and renal Impairment
    3. Sitagliptin (Januvia) is less associated with CHF exacerbation
    4. Scirica (2013) N Engl J Med 369(14):1317-26 [PubMed]
  8. Severe, persistent Joint Pain (rare)
    1. Stop agent if suspect Gliptin-induced pain (and avoid other Gliptins)
    2. Consider other possible causes (e.g. Statin induced Myopathy)
    3. FDA Alert
      1. http://www.fda.gov/drugs/drugsafety/ucm459579.htm
  • Safety
  1. Unknown safety in pregnancy (but generally avoided)
  2. Unknown safety in Lactation
  • Drug Interactions
  1. Significant CYP3A4 Drug Interactions
    1. Decrease Saxagliptin dose with strong CYP3A4 Inhibitors (e.g. Ketoconazole)
  • Efficacy
  1. No longterm cardiovascular benefit (DPP-4 Inhibitor in general)
    1. Green (2015) N Engl J Med 373(3): 232-42 [PubMed]
    2. Scirica (2013) N Engl J Med 369(14): 1317-26 [PubMed]
    3. White (2013) N Engl J Med 369(14): 1327-35 [PubMed]
  2. Lowers HBA1C 0.5 to 0.9% with a mean 0.6% (DPP-4 Inhibitor in general)
    1. Contrast with Metformin, Sulfonylureas, GLP-1 Agonists, Pioglitazone lower A1C 1.0 to 1.5% at generic costs
    2. When combined with other hypoglycemics, its Glucose lowering effects are not additive
  • Resources
  1. Saxagliptin (DailyMed)
    1. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=c5116390-e0fe-4969-94cb-e9de5165fbab
  • References
  1. (2013) Presc Lett 20(8):46
  2. Jones (2007) Am Fam Physician 75:1831-5 [PubMed]
  3. Steinberg (2019) Am Fam Physician 99(4): 237-43 [PubMed]
  4. Vaughan (2024) Am Fam Physician 109(4): 333-42 [PubMed]