But not so fast!  Medical therapy for type 2 diabetes is changing for the better with the introduction of two novel classes of medicines.  The first is the oral SGLT2 inhibitors  ( empagliflozin / Jardiance®  and canagliflozin/Invokana®).   The second is the injectable GLP-1 receptor agonists  ( liraglutide/Victoza®  and semaglutide / Ozempic® ).  These medicine not only lower HbA1c (so what, who cares) but improve outcomes patients and I care about.

As nicely summarized in Table 8.1 of the American Diabetes Association's 2018 Treatment Guidelines  entitled " Drug Specific and Patient Factors to Consider When Selecting Antihyperglycemic Treatment in Adults with Type 2 Diabetes ," only oral empagliflozin/Jardiance®  and injectable liraglutide/ Victoza® are recognized by the Food and Drug Administration  to achieve better cardiovascular outcomes .  Among the once weekly GLP-1 receptor agonists , only semaglutide / Ozempic®  has demonstrated a cardiovascular benefit and is therefore preferred over competing agents such as Dulaglutide / Trulicity® .  Furthermore, only empagliflozin/Jardiance®, canagliflozin / Invokana® , and liraglutide / Victoza® reduce the progression of diabetic kidney disease , an important outcome.  Thus, while these new medicines don't reduce all diabetes complications, they do address two of the most important, namely cardiovascular disease  and renal disease .  Now that is genuine progress.  Moreover, both classes lead to weight loss and rarely cause hypoglycemia. They are new and, depending on your plan, can be expensive.

1. Metformin is the preferred initial pharmacological agent for the treatment of diabetes.
2. Long term use of metformin may be associated with vitamin B12 deficiency and periodic measurement of vitamin B12 should be considered in metformin-treated patients.
3. Initiate insulin therapy in patients who have very high hemoglobin A1c levels (>10%) and/or blood glucose levels > 300 mg/dL.
4. Initiate therapy with two medicines in patients with HbA1c > 9%.
5. In patients with established atherosclerotic cardiovascular disease, antihyperglycemic therapy should begin with lifestyle management and metformin and subsequently incorporate an agent proven to reduce major adverse cardiovascular events and cardiovascular mortality (currently empagliflozne/Jardiance®, liraglutide/Victoza, or semaglutide/Ozempic®).
6. For patients not achieving glycemic goals, drug intensification, including consideration of insulin therapy, should not be delayed.
7. Metformin should be continued when used in combination with other agents, including insulin, if not contraindicated and if tolerated.
8. GLP-1 receptor agonists (liraglutide/Victoza® and semaglutide/Ozempic®) should not be used in combination with oral DPP-4 inhibitors (sitagliptin/Januvia®, etc.)