Substitution of Chronic Insulin Therapy with Dipeptidyl Peptidase-4 Inhibitors and Sodium-Glucose Co-transporter-2 Inhibitors

Abstract

Insulin is a very useful and widely used treatment for diabetes. Temporary insulin therapy improves glucose toxicity due to improved β-cell function of the pancreas. Upon achieving glycemic control, insulin treatment could be discontinued and substituted with oral hypoglycemic agents. Nevertheless, insulin therapy is associated with side effects such as hypoglycemia, allergic reactions, and angioneurotic edema. Over this past decade, there have been rapid advances in diabetes treatment, including the introduction of Dipeptidyl peptidase-4 (DPP-4) inhibitors and Sodium-glucose cotransporter-2 (SGLT2) inhibitors. We present here the case
of a patient with type 2 diabetes who discontinued insulin therapy after more than 20 years by switching to oral hypoglycemic agents including a DPP-4 inhibitor and a SGLT2 inhibitor. A 64-year-old man with type 2 diabetes was being treated with Lispro Mix 50 insulin
twice daily. He was started on subcutaneous insulin 20 years ago. He also has hypertension and hyperlipidemia, and visits the home clinic once a month. He consulted the clinic because he strongly wanted to discontinue insulin therapy due to his work situation. At the time, he was taking Lispro Mix 50 insulin twice daily (morning: 10U, evening: 6U) and his HbA1c was 7.3%. His body weight was 47.0 kg, height was 160 cm, and body mass index was 18.4 kg/ m2. His blood pressure was 118/68 mm Hg and his pulse rate was 72 beats per minute. After evaluation of his condition, insulin therapy was discontinued and oral therapy consisting of glimepiride 1 mg/day, teneligliptin 20 mg/day, and canagliflozin 100 mg/day was started. Serum C-peptide and HbA1c were 0.9 ng/ml and 7.3% respectively three months later.