Type 2 diabetes mellitus is a chronic disease that is increasing in global prevalence. An individualized approach to pharmacotherapy should consider costs, benefits beyond glucose control, and adverse events. Metformin is the first-line therapy due to its low cost and effectiveness. Sulfonylureas and thiazolidinediones are additional low-cost oral hypoglycemic classes available in the United States; however, evidence shows variability in weight gain and hypoglycemia. Thiazolidinediones increase fluid retention and are not recommended in patients with New York Heart Association class III or IV heart failure. Newer medications, including glucagon-like peptide-1 receptor agonists and sodium-glucose cotransporter-2 inhibitors, have demonstrated weight loss, reduced cardiovascular events, decreased renal disease, and improved all-cause morbidity and mortality. Sodium-glucose cotransporter-2 inhibitors are recommended for people with known cardiovascular disease, heart failure, and chronic kidney disease but carry an increased risk of urinary tract and mycotic infections. Glucagon-like peptide-1 receptor agonists are contraindicated in patients with active multiple endocrine neoplasia type 2 or a personal or family history of medullary thyroid carcinoma; adverse effects include gastrointestinal upset and pancreatitis. Dipeptidyl-peptidase-4 inhibitors have a low risk of hypoglycemia but may increase the risk of pancreatitis and require a renal dose adjustment. Public and private programs to increase access to newer hypoglycemic medications are increasing; however, there are limitations to access, particularly for uninsured and underinsured people.
More than 38 million people in the United States have diabetes mellitus; 90% to 95% have type 2.1 In 2022, medical and economic costs of $412.9 billion in the United States were attributed to diabetes.2 In the next 10 years, estimates predict a near doubling of the number of affected people in the United States, with a greater prevalence among low-income populations.3,4 People with annual incomes below the poverty level have the highest prevalence of a diabetes diagnosis and complication rates.1 Food insecurity, food deserts, and lack of access to safe exercise spaces in lower socioeconomic areas complicate efforts to prevent and control type 2 diabetes.5,6 Racial and ethnic disparities also exist. A total of 14.5% of American Indians and Alaska Natives, 12.1% of non-Hispanic Blacks, 11.7% of Hispanics, 9.1% of non-Hispanic Asians, and 6.9% of non-Hispanic Whites are diagnosed with diabetes; however, millions more people are undiagnosed.7–9
WHAT'S NEW ON THIS TOPIC
| In 2016, the U.S. Food and Drug Administration revised the metformin label to reflect its safety in people with an estimated glomerular filtration rate of 30 mL per minute per 1.73 m2 or greater. When the estimated glomerular filtration rate is between 30 and 45 mL per minute per 1.73 m2, a maximum daily dosage of 1,000 mg and close monitoring of renal function are recommended. |
| A large randomized clinical trial showed that empagli flozin (Jardiance), a sodium-glucose cotransporter-2 inhibitor, reduced a composite outcome of myocardial infarction, stroke, and cardiovascular death in people with established arteriosclerotic cardiovascular disease compared with placebo. |
| A 2023 systematic review found that glucagon-like peptide-1 receptor agonists and sodium-glucose cotransporter-2 inhibitors reduce cardiovascular-related deaths, nonfatal myocardial infarction, hospital admissions, end-stage renal disease, and all-cause mortality. |
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