Skip to main content
Dr. van Walraven recommends we keep things simple, and use SGLT2 inhibitors as second-line diabetic agents after metformin. The rationale presented is based on "the importance of good glucose control in the treatment of type 2 diabetes" (take that evidence as you will), and the retrospective cohort study by Iskander et al. showing that new prescriptions of SGLT2 inhibitors had no higher rates of acute kidney injury (1 in 90 patients) than new prescriptions of DPP4 inhibitors (1 in 50 patients). To paraphrase, "why worry?" Whether DPP4 inhibitors are an appropriate comparator, or how this risk of AKI compares to potential clinical benefits of these medications, is glossed over.
The only reason to bother thinking any more about diabetes treatment options, according to this article, is if cost is an issue. SGLT2 inhibitors cost approximately $1,185/year. As a comparison, gliclazide costs approx. $60/year; glyburide approx. $85/year; and common insulins at 10-40 units/day are $150-600/year (NPH) and $210-850/year (Basaglar); data from RxFiles.
Many diabetic patients struggle with affordability of healthy food choices and leisure time for exercise. Even for those patients whose medication costs are shared among other tax-payers or insurance-premium-payers, my unanswered question is this: are SGLT2 inhibitors 20 times as effective as gliclazide, 14 times better than glyburide, or 2-5 times better than insulin, for end-points that matter to patients?