Predictors of clinical responses to DDP-4. My clinical experience.

Among other factors (diet and excercise), you need to take into accont diabetes evolution, age and previous glucose control.

A Type 2 DM patient with less than 3-4 years since diagnosis, who was taken only metformin and the HbA1c is not optimal (depending of age) you add a DPP-4 and you will find and excellent response for several years.

If the patient has a long term Type 2 diabetes and has had an inappropriate glucose control you may expect a failure to this excellent type of agents. Generaly speaking, in those situations you need to provide basal insulin, and if you decide to use a DPP-4 plus metformin you could see good or excelent response in terms of fasting and post prandial glucose. Needeless to say that dietary adherance is crucial and at least 150 min of regular aerobic and strenght excercise must be implemented.

But if the patient has neuropathy and nephropathy, the  situation is different. In patients with these chronic complications you may decided to multiple insulin doses (basal plus regimen). Once you control glycemia, and glucotoxicity is not a problem you may try to gradually reduce  prandial insulin analogs and eventually try the DPP4 alone or with metformin.  If this approach work, you will se results just after few days of prandial insulin is disconitunued, if hyperglycemia ensues, go back to multiple insulin doses (if possible you can measure C peptide, and this can help find out if you will get response to DPP-4).

Despite your concer is on DPP-4 response, I would add that if the patient is obese, has relatively a low diabetes duration you may consider the use of GLP-1 analog with metformin.

Newer agents such as SGL2 agents associated with DPP-4 inhibitors could be tried as well, but further studies need to be done to evaluate this combination.

Do not forget that Type 2 DM patients are insulin deficiency and adding basal insulin is recommeded almost always.

Regards,

JGJM

Thanks sir

i found in my study that the main predictors of best response to treatment with DPP-4 Inhibitors are the younger age, the less BMI, the less DM duration. the more GLP-1 and c-peptide level.  is there any valid study agree with me and support these results.

I agree that shorter diabetes duration and higher postprandial C-peptide level are very important predictors of DPP-4 inhibitors efficacy.