From the Guidelines
Metformin is the best initial treatment for type 2 diabetes.
Key Considerations
- The choice of glucose-lowering therapy should be guided by person-centered treatment factors, including comorbidities and treatment goals and preferences 1.
- Metformin is the preferred initial glucose-lowering medication for most people with type 2 diabetes due to its efficacy, safety, tolerability, low cost, and extensive clinical experience 1.
- Metformin has been shown to be more effective than other pharmacologic agents in reducing glycemic levels, and is not associated with weight gain 1.
- Unless contraindicated, metformin is the drug of choice for patients with type 2 diabetes, in addition to lifestyle modification 1.
Treatment Approach
- A person-centered shared decision-making approach should guide the choice of pharmacologic agents for adults with type 2 diabetes, considering factors such as effectiveness, hypoglycemia risk, impact on weight, cost and access, and individual preferences 1.
- For adults with type 2 diabetes who have not achieved their individualized glycemic goals, selection of subsequent glucose-lowering agents should take into consideration the individualized glycemic and weight goals as well as the presence of other metabolic comorbidities and the risk of hypoglycemia 1.
- In adults with type 2 diabetes who have established/high risk of atherosclerotic cardiovascular disease (ASCVD), heart failure (HF), and/or chronic kidney disease (CKD), the treatment plan should include agents that reduce cardiovascular and kidney disease risk 1.
Additional Considerations
- Glycemic targets and glucose-lowering therapies must be individualized, and diet, exercise, and education remain the foundation of any type 2 diabetes treatment program 1.
- Comprehensive cardiovascular risk reduction must be a major focus of therapy, and all treatment decisions should be made in conjunction with the patient, focusing on his/her preferences, needs, and values 1.
From the Research
Treatment Options for Type 2 Diabetes
The treatment for type 2 diabetes is multifaceted and depends on various factors, including the patient's characteristics and the severity of the disease.
- Metformin is widely recommended as the first-line therapy for type 2 diabetes due to its affordability, tolerability, and efficacy in lowering blood glucose levels 2, 3.
- For patients who do not respond to metformin or require additional therapy, several options are available, including sulphonylureas, dipeptidyl peptidase 4 inhibitors, thiazolidinediones, and sodium-glucose co-transporter 2 inhibitors 4, 3, 5.
- Glucagon-like peptide 1 receptor agonists (GLP-1 RAs) have also been suggested as a potential first-line therapy, particularly for patients with atherosclerotic cardiovascular disease, heart failure, or chronic kidney disease 2, 4.
Second-Line Therapy
The choice of second-line therapy for type 2 diabetes is uncertain, and various guidelines recommend different options.
- The American Diabetes Association/European Association for the Study of Diabetes (ADA/EASD) guidelines recommend SGLT2 inhibitors or GLP-1 RAs as the first choice for second-line therapy in patients with atherosclerotic cardiovascular disease, heart failure, or chronic kidney disease 4.
- The American Association of Clinical Endocrinologists/American College of Endocrinology lists nine hierarchical options for second-line therapy, with GLP-1 RAs as the first recommended therapy 4.
- Other guidelines, such as those from the International Diabetes Federation and the World Health Organization, recommend different options, including sulfonylureas, DPP4 inhibitors, and SGLT2 inhibitors 4.
Individualized Treatment
The choice of treatment for type 2 diabetes should be individualized based on the patient's characteristics, such as age, comorbidities, and medication adherence.
- A retrospective analysis of electronic health records found that treatment with SGLT2 inhibitors, sulphonylureas, DPP4 inhibitors, and thiazolidinediones resulted in similar improvements in glycated haemoglobin (HbA1c) levels at 6 and 12 months 5.
- The study also found that accounting for patients' phenotypic characteristics, such as age and medication possession ratio, may facilitate individualized prescribing and improve treatment outcomes 5.