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Study Protocol

Combining Glucagon-Like Peptide-1 Receptor agonists and Sodium-Glucose Cotransporter-2 Inhibitors in the management of Type 2 Diabetes Mellitus: A protocol for a scoping review

[version 1; peer review: 1 approved with reservations]
PUBLISHED 13 Feb 2025
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Abstract

Introduction

Diabetes treatment has evolved from solely focusing on glucose control to a more patient-centered approach that includes medications designed to reduce specific risks in addition to managing blood glucose control.

Methods and analysis

We propose a scoping review to explore the available clinical research on the combined use of GLP-1RAs and SGLT2is. This review will adhere to the guidelines outlined in the Joanna Briggs Institute Reviewer’s Manual and the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews).

Keywords

Diabetes mellitus; Glucagon-like peptide-1 receptor agonists; Sodium-glucose cotransporter-2 inhibitors.

Article summary

Strengths and limitations of this study

This scoping review will be the first to comprehensively examine the available literature on combined therapy with GLP-1RAs and SGLT2is.

By including all the available literature, this review will provide a comprehensive summary of the effects of combined therapy and trace the progression of research on the combined use of GLP-1RAs and SGLT2is.

This scoping review will focus exclusively pn clinically meaningful outcomes; surrogate and intermediate outcomes will not be considered.

Introduction

Diabetes mellitus (DM) is one of the leading non-communicable diseases and a significant risk factor for other non-communicable conditions such as cardiovascular and chronic kidney diseases. These conditions account for a high proportion of deaths and disability around the world,1 and DM incidence is expected to rise, especially in low and middle-income countries.2

The approach to DM treatment has evolved from a strict glucose control aimed at reducing the risk of micro- and macrovascular complications35 to a more patient-centered strategy. This new paradigm emphasizes reducing the risk of conditions such as cardiovascular disease, heart failure, and kidney disease through medications with a disease-modifying effect, independent of glucose control.3,4

Most recent advancements in DM treatment stem from the clinical evidence on two classes of medication: glucagon-like peptide-1 receptor agonists (GLP-1RAs)58 and sodium-glucose cotransporter-2 inhibitors (SGLT2is). Individually, these medications meet the glucose reduction and cardiovascular safety requirements for DM and they modify the risk of cardiovascular events, heart failure hospitalizations, and progression of kidney disease. They also are related to modest weight loss and a low risk of hypoglycemia.912

While guidelines recommend combining DM treatments as simultaneous or add-on therapies13,14—a natural progression in T2D management—most clinical trials are structured to evaluate a single interventions, including those on GLP-1Ras and SGLT2is. Real-world clinical practice often differs significantly from the controlled environment of clinical trials. Following guidelines recommendations, combined therapy with GLP-1RAs and SGLT2is is expected to become one of the most commonly prescribed treatments for DM. Recently, meta-analyses of clinical trials have synthesized the combined effects of these two drug classes. However, observational studies and post hoc analyses on combination therapy and its impact on key outcomes are likely to offer a more extensive body of evidence. This prompted us to design a scoping review to map the clinical research landscape surrounding combined GLP-1Ras and SGLT2is therapy, focusing on its effects on metabolic, cardiovascular, and renal outcomes.

Methods

Scoping review

This is a scoping literature review on the body of research on the combined use of GLP-1Ras and SGLT2is in people with T2DM.

The scoping review methodology was chosen to map the range of evidence on this topic, summarize research findings, and identify gaps for further research.13 This review will follow the approach for scoping reviews as outlined in the Joanna Briggs Institute Reviewer’s Manual14 and will adhere to the PRISMA-ScR guidelines.15

The research question

What is the scope of published evidence on the effects of using GLP-1Ras and SGLT2is in individuals with T2DM?

The research sub-questions are:

  • 1. Does the combined use of GLP-1Ras and SGLT2is differ from their separate use in terms of metabolic control, weight change, major cardiovascular events, hospitalizations for heart failure, major renal events, and adverse events?

  • 2. Are there clinical characteristics that influence the response to combined therapy with GLP-1Ras and SGLT2is?

  • 3. Are there differences in the effects based on the specific types of GLP-1Ras and SGLT2is used in combination?

Inclusion criteria

To be included in the review, studies must meet the following criteria:

Report on the combined use of GLP-1Ras and SGLT2is in individuals with T2DM.

Include all types of research reports such as case reports and case series.

Exclude narrative reviews.

Search methods for identification of studies.

Electronic searches

The following databases will be searched from inception to the specified date.

MEDLINE (Pubmed) until September 2024.

Embase until September 2024.

Studies in any language, country, and date will be included. Finally, we will screen reference lists from relevant published studies. The details of the search strategy are provided in Supplementary Table 1.

Data collection and charting

Study selection

To determine which studies should be included, two authors (CEBM and AFSR) will independently review the titles and abstracts of all records retrieved from the search. All articles deemed potentially relevant will be read in full. In case of any disagreements, a third author (JC) will intervene to resolve and provide justification them in a group meeting.

The selection process will follow the recommendations of the PRISMA-ScR checklist,15 and a PRISMA flowchart illustrating the study selection will be provided according to the PRISMA statement.16

Data charting

Relevant information from each included study will be recorded in a data charting form with the following fields: author(s), year of publication, country of origin, if the combination was an add-on, study population, and sample size, study design, intervention or exposition type and details of these, comparator, outcomes and elements of these, and key findings that relate to the scoping review questions.

Presentation of the results

A narrative report will summarise the extracted data within the following conceptual categories: metabolic outcomes, cardiovascular outcomes, renal outcomes, and adverse events. The determination of these conceptual categories will be an iterative process, with potential adjustments after the review if necessary.

Discussion

This review synthesizes the evidence on the metabolic, cardiovascular, and renal outcomes of combined GLP-1Ras and SGLT2is therapy in individuals with DM. Evidence suggests potential benefits from this combined therapy in managing cardiovascular disease,17,18 kidney disease,19 synergistic pathways to enhance glucose control,20 and promoting weight loss.21 Understanding whether these potential benefits translate into clinically meaningful changes for people with DM is essential, which is why this scoping review focuses on clinically significant outcomes. for people with DM. This is why we have centered this scoping review on clinically significant outcomes. Additionally, we plan to investigate whether any differences exist when the combination therapy is used simultaneously or as an add-on approach, as this distinction could guide future research.

Ethics and dissemination

We intend to publish the results in a specialized peer-reviewed journal and present them at local, national, and international conferences. The paper will also serve as the basis for a position statement in our country.

Author contributions

CEBM conceived and designed the review, led the development of the search strategy, and offered guidance for protocol design. All authors critically reviewed and contributed to the final version of the manuscript.

Patient and public involvement

Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Ethics and dissemination

We intend to publish the results in a specialized peer-reviewed journal and present them at local, national, and international conferences. They will also be used as educational material in meetings. Ethical approval and consent were not required.

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CITE
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Builes-Montaño CE, Suarez-Rodriguez AF and Carreño J. Combining Glucagon-Like Peptide-1 Receptor agonists and Sodium-Glucose Cotransporter-2 Inhibitors in the management of Type 2 Diabetes Mellitus: A protocol for a scoping review [version 1; peer review: 1 approved with reservations]. F1000Research 2025, 14:202 (https://doi.org/10.12688/f1000research.159628.1)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
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Open Peer Review

Current Reviewer Status: ?
Key to Reviewer Statuses VIEW
ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions
Version 1
VERSION 1
PUBLISHED 13 Feb 2025
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Reviewer Report 09 Apr 2025
Paschalis Karakasis, Aristotle University of Thessaloniki, Thessaloniki, Greece 
Approved with Reservations
VIEWS 1
The authors present protocol for a scoping review that aims to synthesize the current evidence on the combined use of GLP-1 receptor agonists (GLP-1RAs) and SGLT-2 inhibitors (SGLT-2is) in the treatment of type 2 diabetes mellitus (T2DM).

... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Karakasis P. Reviewer Report For: Combining Glucagon-Like Peptide-1 Receptor agonists and Sodium-Glucose Cotransporter-2 Inhibitors in the management of Type 2 Diabetes Mellitus: A protocol for a scoping review [version 1; peer review: 1 approved with reservations]. F1000Research 2025, 14:202 (https://doi.org/10.5256/f1000research.175387.r375414)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.

Comments on this article Comments (0)

Version 1
VERSION 1 PUBLISHED 13 Feb 2025
Comment
Alongside their report, reviewers assign a status to the article:
Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions
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