Medications for Type 2 Diabetes

The 2020 American Diabetes Association (ADA) guidelines recommend the following medications for type 2 diabetes (DM2):

  1. Metformin is the initial drug treatment for patients with DM2. Metformin offers several advantages, including its effectiveness in lowering A1c levels, affordability, improvement of insulin resistance, potential for weight loss, absence of hypoglycemic episodes, and extensive clinical safety data spanning back to its approval in France in 1957 and the United States in 1995.
  2. For patients with established cardiovascular disease or risk factors, the ADA recommends considering a GLP1 agonist as the second-line medication, as these drugs have proven cardiovascular benefits. Examples of GLP1 agonists include Ozempic, Victoza, and Trulicity.
    • However, if a patient with DM2 also has heart failure or chronic kidney disease (defined by LVEF <45%, eGFR 30-60, or urinary albuminuria >300), an SGLT2 inhibitor could be used as a second-line medication option. Examples of SGLT2 inhibitors include Invokana, Jardiance, and Farxiga.
  3. As a third-line option, the ADA suggests adding a GLP1 agonist if the patient is already on Metformin and an SGLT2 inhibitor, or adding an SGLT2 inhibitor if the patient is already taking Metformin and a GLP1 agonist.
  4. Fourth-line therapies may include sulfonylureas, basal insulin, DDP4 inhibitors, or TZDs, provided there is no heart failure present.

It is important to note that the drug recommendations provided above are general and serve only as a guideline. The ultimate clinical decision should consider factors such as medication tolerability, cost, clinical context, glucose control, the patient’s weight loss goals, comorbidities, and patient preferences.

Dr. Tashko


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2020 ADA GUIDELINES

Medication use in DM2

  • Metformin is the preferred initial pharmacologic agent for the treatment of type 2 diabetes.
  • Once initiated, metformin should be continued as long as it is tolerated and not contraindicated; other agents, including insulin, should be added to metformin.
  • Early combination therapy can be considered in some patients at treatment initiation to extend the time to treatment failure.
  • The early introduction of insulin should be considered if there is evidence of ongoing:
    • Catabolism, like weight loss.
    • Symptoms of hyperglycemia
    • A1c levels >10%
    • Blood glucose ≥300 mg/dL
    • Atherosclerotic cardiovascular disease or indicators of high risk.
    • Kidney disease
    • Heart failure
  • A sodium-glucose cotransporter 2 inhibitor (SGLT2i) or glucagon-like peptide 1 receptor agonist (GLP1a) with demonstrated cardiovascular disease benefit is recommended as part of the glucose-lowering regimen independent of A1c and in consideration of patient-specific factors.