An updated clinical guideline from the American College of Physicians recommends adding a sodium-glucose cotransporter-2 (SGLT2) inhibitor or glucagon-like peptide 1 (GLP-1) agonist to standard treatment for type 2 diabetes in adults. The update is published in the Annals of Internal Medicine.
In a 2017 guideline, the American College of Physicians Clinical Guidelines Committee recommended metformin, added to lifestyle modifications, when needed to improve glycemic control in adults with type 2 diabetes. The 2024 guideline incorporates evidence on the effectiveness and harms of newer pharmacologic agents, including GLP-1 agonists, SGLT2 inhibitors, and dipeptidyl peptidase-4 (DPP-4) inhibitors. The systematic review and recommendations focus on the benefits and harms of the newer treatments, with consideration of patients’ values and preferences and medication costs.
The guideline includes a strong recommendation for SGLT2 inhibitors or GLP-1 agonists to metformin and lifestyle changes for adults with type 2 diabetes and inadequate glycemic control. That recommendation is based on high-certainty evidence that SGLT2 inhibitors can lower the risk of all-cause mortality, major adverse cardiovascular events, progression of chronic kidney disease, and heart failure hospitalization. Use of GLP-1 agonists reduces all-cause mortality and major adverse cardiovascular events as well as the risk of stroke.
The new document also includes a strong recommendation against adding a DPP-4 inhibitor to standard treatment for type 2 diabetes. That recommendation reflects a lack of evidence that DPP-4 inhibitors reduce morbidity or all-cause mortality.
Weight loss of at least 10% of body weight was a prioritized outcome, but the review did not identify adequate information for analysis. The committee notes that the guideline does not address effects on glycemic control—a common goal of type 2 diabetes treatment.
Cost-effectiveness analysis showed no substantial differences between SGLT2 inhibitors and GLP-1 agonists. The committee notes the high costs of these newer medication classes, for which generic formulations are not currently available. Although lower-cost options are available, evidence shows that they are inferior in reducing all-cause mortality and morbidity.
The updated guideline states that clinicians should prioritize the addition of SGLT2 inhibitors in patients with type 2 diabetes and congestive heart failure and GLP-1 agonists in those who are at increased risk for stroke or for whom weight loss is an important treatment goal. The recommendations and clinical considerations are summarized in an interactive visual clinical guideline [Qasseem A, et al.; Clinical Guidelines Committee of the American College of Physicians. Newer pharmacologic treatments in adults with type 2 diabetes: A clinical guideline from the American College of Physicians. Ann Intern Med 2024; 177:658–666. doi: 10.7326/M23-2788].
