New Kid on the Block: Linagliptin (Tradjenta)

Never be the first to prescribe a new medication, but never be the last either. Despite Big Pharma's attempt to induce us to prescribe the newest & latest, too often me-too drugs, we teach our resident physicians to look deeper for meaningful reasons, eg outcomes that matter, to switch.  For instance, LDL lowering isn't enough - we want to see a decrease in cardiovascular events & mortality.

I mention this because the Food & Drug Administration just approved linagliptin (Tradjenta), another dipeptidyl peptidase-4 (DPP-4) inhibitor, for treatment of type 2 diabetes.  This latest drug is the 3rd in the class started by sitagliptin (Januvia) in 2006 and joined by saxagliptin (Onglyza) in 2009.  The beauty of this class is that the risk for hypoglycemic is low when used by itself or in combination w/metformin or a glitazone, eg pioglitazone (Actos) or rosiglitazone (Avandia).

These DPP-4 inhibitors work by inhibiting the breakdown of incretin.  Higher incretin levels thus leads to both lower glucagon & higher insulin levels, both of which lower glucose and tend to delay gastric emptying.  Alternatively, one can increase incretin by injecting either exenatide (Byetta) or liraglutide (Victoza).

The good news for our patients w/diabetes is that they have many options from which to choose to assist them in lowering their blood sugars and minimizing their risk for dying early or suffering from heart attacks, strokes, kidney failure, amputations, and erectile dysfunction.  However, as providers, we have to look long & hard to see if new therapies have any decided advantage over (slightly) older options, which by now have hopefully demonstrated safety.

So never be the first but never be the last to prescribe a new medication.  But above all else, do not harm.