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 seeing 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, overweight, or obesity. And semaglutide (Ozempic) is now approved for patients with type 2 diabetes and chronic kidney disease (CKD).
Use the table below to help guide evidence-based choices.
Emphasize “starting low and going slow”...to improve tolerability of GLP-1 agonists. Caution about GI side effects and consider risks...such as gallbladder disease, rare pancreatitis, etc.
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.
Discuss 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.
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.