American College of Physicians Reaffirms De-emphasis on Glucose Control and Adds New Treatments for Type 2 Diabetes

According to the American College of Physicians, what is the role of newer medicines for type 2 diabetes?

Continuing to be ahead of the curve compared with other professional societies, the American College of Physicians published the guideline to reaffirm an A1C goal of 7% to 8% for most people with type 2 diabetes. Rather than focusing solely on blood glucose control, they also suggest adding newer treatments, such as sodium-glucose cotransporter-2 (SGLT-2) inhibitors (eg, dapagliflozin [Farxiga], empagliflozin [Jardiance]) or glucagon-like peptide-1 (GLP-1) receptor agonists (eg, liraglutide [Victoza], semaglutide [Ozempic]), for most patients because of their demonstrated benefit on morbidity and mortality, with the choice of treatment based on comorbidity. The guideline recommends against using dipeptidyl peptidase-4 (DPP-4) inhibitors because of a lack of demonstrated benefit on morbidity and all-cause mortality. (Level of Evidence = 5)

The guideline from the American College of Physicians updates its 2017 recommendations for the treatment of patients with type 2 diabetes and considers the role of newer treatments that have demonstrated benefit on all-cause mortality and morbidity. The authors reiterate that the goal of long-term blood glucose control is an A1C level of 7% to 8%, with the specific number individualized to patients based on their goals, comorbidities, life expectancy, and risks associated with hypoglycemia. Glucose control should be relaxed in patients with an A1C level of less than 6.5%. The guideline continues to recommend metformin as first-line therapy, with early addition of an SGLT-2 inhibitor or GLP-1 receptor agonist (strong recommendation and high-certainty evidence). Based on evidence of no benefit—or perhaps increased morbidity—the authors do not recommend routine treatment with DPP-4 inhibitors (strong recommendation and high-certainty evidence). The guideline is based on a systematic review of recent literature by a working group without intellectual, professional, or financial conflicts of interest. The group included internists, an epidemiologist, and a panel of public members.

Study design: Practice guideline

Funding source: Self-funded or unfunded

Setting: Various (guideline)

Reference: Qaseem A, Obley AJ, Shamliyan T, et al.; Clinical Guidelines Committee of the American College of Physicians. Newer pharmacologic treatments in adults with type 2 diabetes: a clinical guideline from the American College of Physicians. Ann Intern Med. 2024;177(5):658-666.

Editor’s Note: Dr. Shaughnessy is an assistant medical editor for AFP.