Choosing glucose-lowering medication if there is a compelling need to minimize hypoglycemia, there is a compelling need to minimize weight gain or promote weight loss, or cost is a major issue. Beyond these steps, many patients with type 2 diabetes will eventually require and benefit from further intensification to insulin therapy. 1SGLT2 inhibitor labeling varies by region and individual agent with regard to indicated level of eGFR for initiation and continued use. 2Semaglutide > liraglutide > dulaglutide > exenatide > lixisenatide. 3If no specific comorbidities (i.e., no established CVD, low risk of hypoglycemia, and lower priority to avoid weight gain or no weight-related comorbidities). 4Choose later-generation sulfonylurea to lower risk of hypoglycemia. Glimepiride has shown similar cardiovascular safety to DPP4 inhibitors. 5Consider region-specific costs of drugs. In some countries, TZDs are relatively more expensive and DPP-4 inhibitors are relatively less expensive. 6See figure 6. The cost of these drugs is relatively similar in the United States. DPP4i, DPP-4 inhibitor; GLP-1RA, GLP-1 receptor agonist; SGLT2i, SGLT2 inhibitor; SU, sulfonylurea. Adapted from refs. 13 and 14.
