New First-Line Options Emerging for Type 2 Diabetes Care

Glucagon-like peptide-1 receptor agonists (GLP-1 RA) and sodium-glucose cotransporter-2 inhibitors (SGLT-2i) have cardiovascular and renal protective benefits. In 2022, the American Diabetes Association/European Association for the Study of Diabetes added GLP-1 RA and SGLT-2i to the first-line therapy recommendations for patients with type 2 diabetes (T2D). Metformin was originally the only approved first-line medication for T2D treatment since its approval nearly 2 decades ago. Metformin is cost effective and effectively improves a patient’s glycemic status. Researchers at Western University of Health Sciences School of Pharmacy and HOAG’s Mary and Dick Allen Diabetes Center conducted a literature search in June 2023 comparing T2D treatment options. The search concluded GLP-1 RA and SGLT-2i should be considered as first line since they have cardiovascular and renal benefits.

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The researchers reviewed the most recent diabetes guidelines and searched PubMed to compare metformin against newer agents. The review included searching for evidence that supports metformin’s first line recommendation. Additionally, the researchers looked for studies to support GLP-1 RA and SGLT-2i’s effectiveness over metformin as a monotherapy option.

Investigators of the study concluded that the benefits of GLP-1 RA and SGLT-2i are independent of their use with metformin. GLP-1 RA and SGLT-2i are considerable first-line options for patients with cardiovascular risks, renal complications, or weight loss requirements. But studies on GLP-1 RA and SGLT-2i still need to be done to determine long-term safety outcomes. Metformin has been studied for 2 decades and has an abundance of data to back its safety. A GLP-1 RA and SGLT-2i’s costs are much higher than metformin’s, with its affordability positively impacting glycemic outcomes and adherence.

GLP-1 RA and SGLT-2i are effective T2D medications with a multitude of benefits for various patient groups. Metformin is no longer the only first-line recommendation for T2D. Prescribers need to take a patient-centered approach when choosing a patient’s first-line therapy. A patient’s diabetes medication options should take into account their cardiovascular and renal status in addition to weight loss needs. Last, the study authors mentioned that GLP-1 RA and SGLT-2i’s superiority over metformin requires a head-to-head study to make a proper conclusion.

Reference

Andraos J, Smith SR, Tran A, et al. Narrative review of data supporting alternate first-line therapies over metformin in type 2 diabetes. J Diabetes Metab Disord. 2024;23(1):385-394. doi:10.1007/s40200-024-01406-6