The New Medications for Type 2 Diabetes: Expert Guidance and Key Questions Every Patient Should Ask

Introduction

This article is based on recommendations and analysis from the 2024 publication “Newer Pharmacologic Treatments in Adults With Type 2 Diabetes: A Clinical Guideline From the American College of Physicians”, published in the Annals of Internal Medicine. The guideline was developed by the Clinical Guidelines Committee (CGC) of the American College of Physicians (ACP)—a multidisciplinary team of 14 experts, primarily internal medicine specialists, along with representatives from the general public, clinical pharmacologists, and epidemiologists. All recommendations are grounded in a systematic review and network meta-analysis of randomized controlled trials that evaluated the effectiveness, safety, patient preferences, and economic aspects of newer medications for treating type 2 diabetes in adults.

What the Experts Say

This article presents expert opinions derived from ACP’s clinical guideline, based on the most up-to-date scientific evidence for the treatment of adults with type 2 diabetes (T2D) using newer drug therapies. Each section features a guiding question that can help patients, their families, and healthcare providers make informed decisions. We’ve also included explanations in plain language to help all readers better understand the recommendations.

1. When and Why Should an SGLT-2 Inhibitor or GLP-1 Receptor Agonist Be Added to Metformin and Lifestyle Changes?

Expert Recommendation:

"ACP strongly recommends adding a sodium–glucose cotransporter-2 (SGLT-2) inhibitor or a glucagon-like peptide-1 (GLP-1) receptor agonist to metformin and lifestyle modifications in adults with type 2 diabetes who have inadequate glycemic control.

Use an SGLT-2 inhibitor to reduce the risk of all-cause mortality, major cardiovascular events, progression of chronic kidney disease, and hospitalizations due to heart failure.

Use a GLP-1 receptor agonist to reduce the risk of all-cause mortality, major cardiovascular events, and stroke." (Strong recommendation; high-certainty evidence.)

Plain Language Explanation:

If you're living with type 2 diabetes and metformin along with healthy lifestyle changes aren’t enough to manage your blood sugar, your doctor may recommend adding an SGLT-2 inhibitor or a GLP-1 receptor agonist. These medications not only improve blood sugar levels but have been shown to reduce the risk of death, heart attacks, strokes, kidney disease, and heart failure.

2. What Are the Benefits and Risks of the Newer Therapies?

Expert Recommendation:

"The only newer pharmacologic treatments that reduce all-cause mortality compared to placebo or usual care are SGLT-2 inhibitors and GLP-1 receptor agonists.

Both drug classes have side effects and carry specific warnings. SGLT-2 inhibitors are associated with bone fractures, amputations, fungal infections, orthostatic hypotension, and ketoacidosis. GLP-1 receptor agonists are associated with thyroid tumors (in rodents), pancreatitis, acute gallbladder disease, diabetic retinopathy, and others."

Plain Language Explanation:

While these new medications offer significant health benefits, they also come with risks.

• SGLT-2 inhibitors may cause urinary or genital infections, and in rare cases, lead to serious complications like diabetic ketoacidosis or even limb amputation.

• GLP-1 receptor agonists may increase the risk of pancreatitis, gallbladder issues, or vision problems.

Treatment decisions should be personalized, weighing both benefits and risks, and made in close consultation with your healthcare provider.

3. What About DPP-4 Inhibitors—Are They Worth Considering?

Expert Recommendation:

"ACP strongly recommends against adding a DPP-4 inhibitor to metformin and lifestyle changes in adults with type 2 diabetes who have poor glycemic control, due to lack of evidence for reducing complications or mortality." (Strong recommendation; high-certainty evidence.)

Plain Language Explanation:

DPP-4 inhibitors haven’t shown meaningful benefits in lowering the risk of death or serious complications like heart or kidney disease. They may also be more expensive and less effective than other newer medications. That’s why experts don’t recommend using them when metformin and lifestyle changes aren’t enough.

4. Which Medication Should I Choose If I Have Heart Failure, Kidney Issues, or a High Risk of Stroke?

Expert Recommendation:

"Clinicians should prioritize SGLT-2 inhibitors for patients with type 2 diabetes and either heart failure or chronic kidney disease. GLP-1 receptor agonists should be prioritized for those at increased risk of stroke or when weight loss is a key treatment goal."

Plain Language Explanation:

If you have heart failure or kidney disease, SGLT-2 inhibitors are usually the best add-on medication. If your main concern is stroke risk or you want to lose weight, GLP-1 receptor agonists may be a better option. Always talk with your doctor to find the treatment that best matches your personal health profile.

5. What Happens If My Blood Sugar Is Well-Controlled on These New Medications?

Expert Recommendation:

"If the addition of an SGLT-2 inhibitor or GLP-1 receptor agonist results in adequate glycemic control, clinicians should consider reducing or discontinuing sulfonylureas or long-acting insulin due to increased risk of severe hypoglycemia."

Plain Language Explanation:

If your blood sugar is well-controlled with a newer medication, it may be time to lower the dose—or even stop—older medications like sulfonylureas or long-acting insulin. These older drugs can cause dangerous blood sugar drops (hypoglycemia), especially in older adults.

Frequently Asked Questions

1. How Common Is Type 2 Diabetes and Who Is Most at Risk?

Type 2 diabetes affects a large portion of the population. In the U.S., about 14.8% of adults have it (age-adjusted), and globally, the rate is around 10.5%. The condition is more common in people with overweight or obesity and in certain racial and ethnic groups:

• 19% of Black adults

• 21% of Hispanic/Latino adults

• 12% of White adults

People with limited access to healthcare or those living in poverty are at even greater risk of complications and early death.

2. What Are the Main Goals of Treatment for Type 2 Diabetes?

The key goals are:

• Achieving good blood sugar control

• Preventing serious complications like heart disease and kidney failure

These complications account for nearly half of all deaths among adults with type 2 diabetes. So, treatment must target both blood sugar and long-term organ health.

3. What Are the Most Important Risks and Complications I Should Watch For?

As a person with type 2 diabetes, you’re at higher risk for:

• Heart attacks and strokes

• Heart failure

• Chronic kidney disease

• Severe hypoglycemia

• Early death

Diabetes can also reduce your work capacity and add financial stress. Be especially mindful of your heart and kidney health, and work with your doctor to monitor blood sugar levels consistently.

4. What Factors Can Influence the Best Treatment Option for Me?

Choosing the right treatment depends on:

• Age, sex, and ethnicity

• Other health conditions (like heart failure or kidney disease)

• How long you’ve had diabetes

• Your A1c levels

• Your insurance coverage and ability to afford medications

• Your personal treatment preferences and goals

5. What Should I Discuss With My Doctor Before Starting or Changing Medications?

Good questions to ask include:

• What are the potential benefits and side effects of this medication?

• Will this treatment reduce my risk of heart or kidney complications?

• Is this medication a good fit for my overall health and lifestyle?

• What will it cost me? Are there more affordable options?

• How often will I need follow-ups or lab tests to monitor my progress?

ACP recommends that care be a collaborative process between you and your doctor, tailored to your individual needs.

Conclusion

The latest clinical guidance from the American College of Physicians empowers adults with type 2 diabetes to make well-informed treatment decisions. With a systematic, evidence-based approach, this guidance reflects the highest level of medical expertise. By understanding the complexities of type 2 diabetes and the available treatment options, patients can partner effectively with their healthcare team to manage their condition and improve long-term outcomes.

Source: American College of Physicians. Annals of Internal Medicine, 2024. “Newer Pharmacologic Treatments in Adults With Type 2 Diabetes: A Clinical Guideline From the American College of Physicians” https://doi.org/10.7326/M23-2788