What are the treatment options for Type 2 Diabetes Mellitus (T2DM)?

From the Guidelines

The treatment of Type 2 Diabetes Mellitus (T2DM) should start with metformin as the first-line agent, in combination with comprehensive lifestyle modifications, as recommended by the most recent guidelines 1.

Initial Management

Initial management should focus on lifestyle changes including weight loss of 5-10% of body weight, regular physical activity (150 minutes per week of moderate-intensity exercise), and a balanced diet with reduced carbohydrate intake.

• Metformin is typically started at 500mg once or twice daily with meals, gradually increasing to 1000mg twice daily as tolerated to minimize gastrointestinal side effects.
• The goal is to achieve target HbA1c levels (usually <7%) while considering patient-specific factors such as comorbidities, potential side effects, and patient preferences.

Additional Medications

If metformin alone is insufficient to achieve target HbA1c levels, additional medications should be added based on patient-specific factors.

• These include SGLT-2 inhibitors (like empagliflozin 10-25mg daily or dapagliflozin 5-10mg daily), which offer cardiovascular and renal benefits 1.
• GLP-1 receptor agonists (such as semaglutide 0.25-1mg weekly subcutaneous injection) can be considered for their weight loss and cardiovascular benefits.
• DPP-4 inhibitors (sitagliptin 100mg daily), sulfonylureas (glipizide 5-20mg daily), or insulin therapy may also be used for more severe cases or based on specific patient needs.

Ongoing Management

Regular monitoring of blood glucose levels, quarterly or biannual HbA1c testing, and annual screening for complications (retinopathy, nephropathy, neuropathy) are essential components of ongoing management.

• A person-centered shared decision-making approach should guide the choice of pharmacologic agents, considering factors such as cardiovascular and renal comorbidities, effectiveness, hypoglycemia risk, impact on weight, cost, and individual preferences 1.
• The treatment plan should be reevaluated at regular intervals (e.g., every 3–6 months) and adjusted as needed to incorporate specific factors that impact choice of treatment.

From the FDA Drug Label

JARDIANCE has been studied as monotherapy and in combination with metformin, sulfonylurea, pioglitazone, linagliptin, and insulin. A total of 986 patients with type 2 diabetes mellitus participated in a double-blind, placebo-controlled trial to evaluate the efficacy of JARDIANCE monotherapy. Add-On Combination Therapy with Metformin A total of 637 patients with type 2 diabetes mellitus participated in a double-blind, placebo-controlled trial to evaluate the efficacy of JARDIANCE in combination with metformin Initial Combination Therapy with Metformin A total of 1,364 patients with type 2 diabetes mellitus participated in a double-blind, randomized, active-controlled trial to evaluate the efficacy of JARDIANCE in combination with metformin as initial therapy compared to the corresponding individual components Add-On Combination Therapy with Metformin and Sulfonylurea A total of 666 patients with type 2 diabetes mellitus participated in a double-blind, placebo-controlled trial to evaluate the efficacy of JARDIANCE in combination with metformin plus a sulfonylurea

The treatment options for Type 2 Diabetes Mellitus (T2DM) include:

• Monotherapy: JARDIANCE
• Combination therapy:
  • JARDIANCE with metformin
  • JARDIANCE with sulfonylurea
  • JARDIANCE with metformin and sulfonylurea
  • JARDIANCE with pioglitazone
  • JARDIANCE with linagliptin
  • JARDIANCE with insulin 2 2

From the Research

Treatment Options for Type 2 Diabetes Mellitus (T2DM)

The treatment options for T2DM include:

• Lifestyle changes, such as diet and exercise 3, 4, 5, 6, 7
• Oral antidiabetic agents, including:
  • Metformin, which is often the first choice of treatment for most patients 4, 5, 6, 7
  • Sulphonylureas 5, 6, 7
  • Thiazolidinediones and glitazones 3, 5, 7
  • Alpha-glucosidase inhibitors 3, 5, 7
  • Glucagon-like peptide-1 agonists 3, 5, 6, 7
  • Dipeptidyl peptidase-4 inhibitors 3, 5, 6, 7
  • Amylin receptor agonist pramlintide 3, 5, 7
• Injectable agents, including:
  • Insulin 5, 6, 7
  • Incretin-mimetics, such as exenatide and liraglutide 3, 6
• Other treatments, such as:
  • Peroxisome proliferator-activated-receptor-γ agonists (thiazolidinediones, pioglitazone, and rosiglitazone) 3
  • Short-acting, nonsulfonylurea secretagogue, meglitinides (repaglinide and nateglinide) 3
  • Colesevelam (a bile acid sequestrant) 3

Patient-Centered Approach

Treatment should be individualized and consider factors beyond glycemic control, including:

• Cardiovascular risk reduction 6
• Patient comorbidities 6
• Route of administration 6
• Patient preference 6
• Cost 6

Recent Developments

Recent studies have shown that certain medications, such as empagliflozin, liraglutide, and semaglutide, can reduce cardiovascular risk in patients with T2DM 6. These findings have prompted updates to treatment guidelines, recommending consideration of these agents for patients with suboptimally controlled long-standing T2DM and established atherosclerotic cardiovascular disease 6.