Empagliflozin with linagliptin

How it works

Empagliflozin promotes urinary glucose excretion via SGLT2 inhibition, while linagliptin raises incretin hormone levels to enhance glucose-dependent insulin secretion and suppress glucagon.

Prescribing in practice

• The most important safety point is the risk of euglycaemic diabetic ketoacidosis from the SGLT2 component, requiring sick-day rules and withholding during acute illness, dehydration, or surgery.
• Linagliptin carries a risk of acute pancreatitis and, rarely, severe joint pain and bullous pemphigoid, while empagliflozin predisposes to genital and urinary infections and rare Fournier's gangrene.
• Linagliptin needs no renal dose adjustment, but empagliflozin has renal thresholds governing use, so confirm renal function before starting.

Monitoring

Monitor renal function, HbA1c, hydration and weight, and remain alert for ketoacidosis and for symptoms of pancreatitis.

Counselling the patient

• Stop the medicine and seek urgent help if acutely unwell, dehydrated, or if you develop nausea, vomiting, abdominal pain, or breathlessness.
• Report severe or persistent abdominal pain, which could indicate pancreatitis.
• Report any genital soreness or itching and maintain good genital hygiene.

Evidence & guidelines

NICE recommends SGLT2 inhibitors in type 2 diabetes, and empagliflozin's cardiovascular benefit was established in the EMPA-REG OUTCOME trial.