You’ll continue to see SGLT2 inhibitors and GLP-1 agonists gain traction as first-line agents for many adults with type 2 diabetes.
We’re used to prescribing metformin first for the majority of these patients...due to its established efficacy, safety, and low cost.
But recent evidence and updated guidelines continue the shift toward a more individualized approach to target the common comorbidities of diabetes (CV disease, heart failure, obesity, etc).
For example, consider a GLP-1 agonist or the dual GIP/GLP-1 agonist tirzepatide for patients with metabolic liver disease or overweight or obesity. And semaglutide (Ozempic) is now approved for patients with type 2 diabetes and CKD.
Use the table below to help guide evidence-based choices.
Continue to weigh side effects...and prior auths or high co-pays.
Caution about GI side effects with GLP-1 agonists. And consider risks (gallbladder disease, rare pancreatitis, etc) before prescribing.
Keep in mind, these meds can delay gastric emptying...increasing concerns about peri-op aspiration and symptoms mistaken for ileus.
And these meds cost about $1,000/month...most are injectable...and shortages are an ongoing issue.
Evaluate risks with SGLT2 inhibitors...since they’re linked to volume depletion, genital yeast infections, etc. Be aware, these meds can cause euglycemic ketoacidosis...and may need to be held around surgery, during vomiting or severe diarrhea, etc. And they cost about $600/month.
SGLT2 inhibitors can be started at an eGFR of 20 mL/min/1.73 m2 for kidney and CV benefits...and continued until dialysis starts.
For more guidance, get our resources Stepwise Treatment of Type 2 Diabetes and Diabetes Medications: Cardiovascular and Kidney Impact.
- American Diabetes Association Professional Practice Committee. 9. Pharmacologic Approaches to Glycemic Treatment: Standards of Care in Diabetes-2025. Diabetes Care. 2025 Jan 1;48(Supplement_1):S181-S206.
- American Diabetes Association Professional Practice Committee. 10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes-2025. Diabetes Care. 2025 Jan 1;48(Supplement_1):S207-S238.
- Shin H, Paik JM, Everett BM, et al. Comparative Effectiveness of Individual Sodium-Glucose Cotransporter 2 Inhibitors. JAMA Intern Med. 2025 Jan 21. doi: 10.1001/jamainternmed.2024.7357.
- Perkovic V, Tuttle KR, Rossing P, et al. Effects of Semaglutide on Chronic Kidney Disease in Patients with Type 2 Diabetes. N Engl J Med. 2024 Jul 11;391(2):109-121.
- Medication pricing by Elsevier, accessed February 2025.