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"Not all glucose lowering therapies are now equal. There has been a shift in the consensus towards patient-centered care where we match therapies to patient profiles, particularly around cardiovascular risk and cardiorenal protection, but also around hypoglycaemia and weight gain." 

 

"Rather than adding treatments on top of each other, we should use smart combinations of therapies based on our understanding of that patient and the underlying pathophysiology." – Prof Melanie Davies

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   Biguanide class, oral tablet

 

  • Mode of action: reduces the production of glucose in the liver and decreased absorption in the intestine, as well as increasing peripheral glucose uptake and increasing insulin sensitivity
  • Beneficial characteristics: Some weight loss, low risk of hypoglycemia, can be combined with all other glucose-lowering medication
  • Common side-effects: Gastrointestinal such as nausea and diarrhea
  • Caution: May not be suited for patients with kidney disease
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To make sure your patients are optimally treated, guidelines recommend reassessing regularly (every 3–6 months) and modifying treatment when necessary.1

 

Still not under control? 

Scroll down to see recommendations for other glucose-lowering medications when patients are not controlled on metformin.

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To make sure your patients are optimally treated, guidelines recommend reassessing regularly (every 3–6 months) and modifying treatment when necessary.1

 

Still not under control? 

Scroll down to see recommendations for other glucose-lowering medications when patients are not controlled on metformin.

Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of death in people with type 2 diabetes, and together with heart failure (HF) and chronic kidney disease (CKD) affecting 15-35% of the population with type 2 diabetes.1,3 Therefore, an important early step is to consider the presence or absence of ASCVD, HF, and CKD, where treatments with proven benefits on morbidity and mortality should be considered.1

 

Specific SGLT2i and GLP-1 RAs have been shown to improve cardiovascular outcomes, as well as secondary outcomes such as HF and progression of renal disease, in patients with established CVD or CKD.1

 If ASCVD predominates, a GLP-1 RA or SGLT2i (if eGFR adequate) with proven benefits should be considered.1,2

If HF or CKD predominated, a SGLT2i with proven benefits is preferred, or if not tolerated/contraindicated/eGFR not adequate, a GLP-1 RA with proven CVD benefits.1,2

*with proven CVD benefits according to label indication 

**with proven HF/CKD benefits according to label indication

 

Oral tablet or injection

 

  • Mode of action: Increases insulin release when blood glucose increases, reduces glucose release from the liver, delays gastric emptying and increases satiety
  • Beneficial characteristics: Promotes weight loss, proven CV benefits*
  • Common side-effects: Gastrointestinal such as nausea and diarrhea
  • Caution: Not suited for patients with previous pancreatitis

*according to label indication

Oral tablet

 

  • Mode of action: Increasing glucose excretion in the urine by preventing reabsorption of glucose from the kidneys
  • Beneficial characteristics: Reduced blood pressure and weight loss, proven CV benefits*
  • Common side-effects: Urinary and genital infections
  • Caution: May not be suited for patients with kidney disease

*according to label indication

icon_calendar_blue

To make sure your patients are optimally treated, guidelines recommend reassessing regularly (every 3–6 months) and modifying treatment when necessary.1

 

No cardiovascular or kidney disease? 

Scroll down to see recommendations for second-line therapy with other patient characteristics in mind

icon_calendar_blue

To make sure your patients are optimally treated, guidelines recommend reassessing regularly (every 3–6 months) and modifying treatment when necessary.1

 

No cardiovascular or kidney disease? 

Scroll down to see recommendations for second-line therapy with other patient characteristics in mind

Oral tablet or injection

 

  • Mode of action: Increases insulin release when blood glucose increases, reduces glucose release from the liver, delays gastric emptying and increases satiety
  • Beneficial characteristics: Promotes weight loss, proven CV benefits*
  • Common side-effects: Gastrointestinal such as nausea and diarrhea
  • Caution: Not suited for patients with previous pancreatitis

*according to label indication

Oral tablet

 

  • Mode of action: Increasing glucose excretion in the urine by preventing reabsorption of glucose from the kidneys
  • Beneficial characteristics: Reduced blood pressure and weight loss, proven CV benefits*
  • Common side-effects: urinary and genital infections
  • Caution: May not be suited for patients with kidney disease

*according to label indication

Oral tablet

 

  • Mode of action: Postprandial increase in insulin production and reduces glucose release by the liver, slow down digestion
  • Beneficial characteristics: Some effect on appetite control
  • Common side-effects: Gastrointestinal such as nausea and diarrhea
  • Caution: Not suited for patients with previous pancreatitis

Oral tablet

 

  • Mode of action: Increase insulin sensitivity
  • Beneficial characteristics: Reduces blood pressure, increases HDL
  • Common side-effects: Weight gain, fluid retention
  • Caution: Not suited for patients with heart failure

Oral tablet

 

  • Mode of action: Stimulates insulin secretion from the pancreas
  • Beneficial characteristics: Inexpensive, good glucose-lowering effect
  • Common side-effects: Weight gain, hypoglycemia
  • Caution: Patients with high risk of hypoglycemia, i.e. older, CKD

 

 

 

If your patients are in need for further intensification following 2nd-line therapy, or if you'd like to understand the underlying rationale for the decisions and guidance for the management of type 2 diabetes, please refer to the EASD/ADA consensus report.

Learn more about GLP-1 RA as a second-line treatment for people living with type 2 diabetes.

Making the best choice for your patient means tackling type 2 diabetes from different angles. Explore the patient cases to see which patients could benefit from a Shift?

Making the best choice for your patient means tackling type 2 diabetes from different angles. Explore the patient cases to see which patients could benefit from a Shift?

1.

Davies MJ, D'Alessio DA, Fradkin J et al. Management of hyperglycaemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care. 2018;41(12):2669-2701.

2.

Buse JB, Wexler D, Tsapas A et al. 2019 Update to: Management of Hyperglycemia in Type 2 Diabetes, 2018. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care. 2020;43(2):487-493.

3.

Mosenzon O, Alguwaihes A , Leon JLA et al. CAPTURE: a multinational, cross-sectional study of cardiovascular disease prevalence in adults with type 2 diabetes across 13 countries. Cardiovasc Diabetol. 2021 Jul 27;20(1):154.