Saxagliptin to Sitagliptin Conversion

Conversion to saxagliptin (Onglyza) should be made once both the provider and patient have been informed and that proper patient education is provided.  

Patients may remain on alternate therapy if there are clinical reasons where switching may be inappropriate.

Saxagliptin Dose

• The recommended dosage of saxagliptin is 2.5 mg or 5 mg once daily taken regardless of meals.
• No dosage adjustment for saxagliptin is recommended for patients with mild renal impairment (creatinine clearance [CrCl] >50 mL/min).
• The dosage of saxagliptin is 2.5 mg once daily for patients with moderate or severe renal impairment, or with end-stage renal disease (ESRD) requiring hemodialysis (creatinine clearance [CrCl] ≤50 mL/min) [saxagliptin should be administered following hemodialysis. Saxagliptin has not been studied in patients undergoing peritoneal dialysis.
• The dosage of saxagliptin is 2.5 mg once daily when coadministered with strong cytochrome P450 3A4/5  inhibitors**

The following dosing table may be used to assist converting patients from another DPP-4 inhibitor to saxagliptin. 

Examples:

• Patient with severe renal impairment (CrCl<30mL/min) who is currently receiving sitagliptin 25mg once daily can be switched to saxagliptin 2.5mg once daily.
• Patient currently receiving linagliptin 5mg and has moderate renal impairment (CrCl ≥30<50mL/min) would receive saxagliptin 2.5mg once daily.

Drug Name	Usual Dose	Dosage Adjustment in Renal Insufficiency			Dosage adjustment with concomitant use of strong CYP3A4/5 inhibitors**
		Mild (CrCl ≥ 50mL/min)*	Moderate (CrCl ≥ 30 to < 50 mL/min) *	Severe (CrCl< 30 mL/min) or ESRD requiring dialysis
Saxagliptin	2.5mg or 5mg once daily	No dosage adjustment needed	2.5mg once daily	2.5mg once daily following hemodialysis	2.5mg once daily
Sitagliptin	100mg once daily	No dosage adjustment needed	50mg once daily	25mg once daily without regard to time of dialysis	No dosage adjustment needed
Linagliptin	5mg once daily	No dosage adjustment needed	No dosage adjustment needed	No dosage adjustment needed	Use of CYP3A4 or P-gp inducers with linagliptin is not recommended
Alogliptin	25mg once daily	No dosage adjustment needed	12.5mg once daily	6.25mg once daily without regard to tome of dialysis	No dosage adjustment needed

*CrCl cutoffs for aloglitpin for mild renal insufficiency is CrCl ≥ 60mL/min; moderate renal insufficiency CrCl ≥ 30 to < 60mL/min

**Examples of strong CYP 3A4/5 inhibitors include but are not limited to: ketoconazole, atazanavir, clarithromycin, indinavir, itraconazole, nefazodone, nelfinavir, ritonavir, saquinavir, telithromycin