Don’t Expect to Always See Metformin First for Type 2 Diabetes

You may see changes in the meds used first for type 2 diabetes.

Metformin will still be the gold standard for most patients...because of its established efficacy and safety and low cost.

But don’t be surprised if some patients start with a GLP-1 agonist (Ozempic, etc) or SGLT2 inhibitor (Farxiga, etc) instead.

That’s because these newer meds also have heart or kidney benefits in patients with certain conditions.

For example, patients with heart disease may start treatment for type 2 diabetes with Ozempic (semaglutide), Trulicity (dulaglutide), or Victoza (liraglutide). These GLP-1 agonists reduce blood glucose...AND the risk of cardiovascular (CV) events, such as heart attack or stroke.

And an SGLT2 inhibitor (Jardiance, etc) may be a good first option for type 2 diabetes in patients who also have heart failure (HF)...since these meds reduce the risk of HF hospitalization or CV death.

Continue to keep patients’ medical conditions the pharmacist can evaluate which diabetes meds may offer the most benefit.

But still expect the choice to consider cost, side effects, etc.

For instance, GLP-1 agonists can cause stomach side effects...carry warnings, such as gallbladder disease...and cost about $1,000/month.

Plus most are injectable...and shortages are an ongoing issue.

SGLT2 inhibitors are linked to problems, such as yeast infections and urinary tract infections...and cost about $600/month.

Anticipate prior auths...and stay alert for errors.

For example, watch for look-alike/sound-alike generic names. GLP-1 agonists all end in “-tide”...dulaglutide, liraglutide, etc. SGLT2 inhibitors all end in “-flozin”...dapagliflozin, empagliflozin, etc.

Double-check dosing. For instance, Ozempic or Trulicity is injected weekly...but Victoza is once daily.

See our resource, Improving Diabetes Outcomes, for tools to compare meds and help care for these patients.

Key References

  • Diabetes Care. 2023 Jan 1;46(Suppl 1):S140-S157
  • Diabetes Care. 2023 Jan 1;46(Suppl 1):S158-S190
  • Diabetes Care. 2022 Nov 1;45(11):2753-2786
  • N Engl J Med. 2023 Jan 12;388(2):117-127
  • Diabetes Care. 2022 Dec 1;45(12):3075-3090
  • Medication pricing by Elsevier, accessed Jan 2023
Pharmacy Technician's Letter. February 2023, No. 390207

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