[Use of dipeptidyl peptidase-4 inhibitors in diabetic patients in special situations]. / Uso de inhibidores de la dipeptidil peptidasa 4 en pacientes con diabetes en situaciones especiales.

Dipeptidyl peptidase-4 inhibitors form part of the group of incretin derivatives and conse-quently have a specific mechanism of action. The incretin effect avoids the adverse ef-fects of classic drugs (sulphonylureas) and provides specific benefits for their use in as-sociation with other drugs and in special situations. Because they have a low risk of pro-ducing hypoglycaemia or weight gain, these inhibitors are useful in combination with other oral antidiabetic drugs and even with insulin, although this latter combination may increase the risk of hypoglycaemia. Large studies of cardiovascular non-inferiority have reported that dipeptidyl peptidase-4 inhibitors are non-inferior to placebo, although one drug (saxagliptin) may increase the risk of hospital admission for heart failure. Because of these cardiovascular advantages, even in peripheral arterial disease, their usefulness in diabetic retinopathy, and their low risk of hypoglycaemia in renal insufficiency, dipeptidyl peptidase-4 inhibitors are the drugs of choice in elderly patients. Given the risk, although still not well defined, these drugs are not recommended in pa-tients with a history or risk of pancreatic disease, in children, in patients with type 1 diabetes, in adolescents, or in pregnant or breastfeeding women. Each of these special situ-ations is discussed in the present article.

Uso de inhibidores de la dipeptidil peptidasa 4 en pacientes con diabetes en situaciones especiales / Use of dipeptidyl peptidase-4 inhibitors in diabetic patients in special situations

Los inhibidores de la dipeptidil peptidasa 4 pertenecen al grupo de los derivados incretí-nicos y, por ello, presentan un mecanismo de acción específco. El efecto incretina permite evitar efectos secundarios de los fármacos clásicos (sulfonilureas) y aportar ventajas específcas para utilizarse en asociación y en situaciones especiales. Su escaso riesgo en la producción de hipoglucemia y de ganancia ponderal los hace útiles en asociación con otros antidiabéticos orales, incluso con insulinas, aunque con ello se pueda aumentar el riesgo de hipoglucemia de estas. Los grandes estudios de no inferioridad cardiovascular han señalado que su comportamiento no es inferior al placebo, aunque en algún fármaco (saxagliptina) haya aumentado el riesgo de hospitalización por insufciencia cardíaca. Estas ventajas cardiovasculares, incluso en la arteriopatía periférica, su buen comportamiento en la retinopatía diabética, junto con su escaso riesgo de hipoglucemia en la insu-fciencia renal, han hecho que sean fármacos de elección en el paciente anciano. Como factor limitante en su uso, dado el riesgo, aún no del todo valorado, no se recomiendan en pacientes con antecedentes de enfermedad pancreática o riesgo de tenerla, ni en niños, en la diabetes tipo 1, en adolescentes, en embarazadas o en mujeres lactantes. Cada una de estas situaciones especiales se desarrolla en el texto

Dipeptidyl peptidase-4 inhibitors form part of the group of incretin derivatives and conse-quently have a specific mechanism of action. The incretin effect avoids the adverse ef-fects of classic drugs (sulphonylureas) and provides specific benefits for their use in as-sociation with other drugs and in special situations. Because they have a low risk of pro-ducing hypoglycaemia or weight gain, these inhibitors are useful in combination with other oral antidiabetic drugs and even with insulin, although this latter combination may increase the risk of hypoglycaemia. Large studies of cardiovascular non-inferiority have reported that dipeptidyl peptidase-4 inhibitors are non-inferior to placebo, although one drug (saxagliptin) may increase the risk of hospital admission for heart failure. Because of these cardiovascular advantages, even in peripheral arterial disease, their usefulness in diabetic retinopathy, and their low risk of hypoglycaemia in renal insufficiency, dipeptidyl peptidase-4 inhibitors are the drugs of choice in elderly patients. Given the risk, although still not well defined, these drugs are not recommended in pa-tients with a history or risk of pancreatic disease, in children, in patients with type 1 diabetes, in adolescents, or in pregnant or breastfeeding women. Each of these special situ-ations is discussed in the present article