Update Diabetes Treatment With SGLT2 Inhibitors & GLP-1 Agonists

Optimize diabetes treatment with SGLT2 inhibitors and GLP-1 agonists based on comorbidities.

As a clinical pharmacist, you’ll continue to see SGLT2 inhibitors and GLP-1 agonists gain traction as first-line agents for many adults with type 2 diabetes. We’re used to prescribing metformin first for the majority of these patients due to its established efficacy, safety, and low cost. But recent evidence and updated guidelines continue the shift toward a more individualized approach to target the common comorbidities of diabetes (CV disease, heart failure, obesity, etc).

For example, consider a GLP-1 agonist or the dual GIP/GLP-1 agonist tirzepatide (Mounjaro) for patients with metabolic liver disease or overweight or obesity. And semaglutide (Ozempic) is now approved for patients with type 2 diabetes and CKD.
Use the table below to help guide evidence-based choices.

Table (1)

Med recommendations for diabetes

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Evaluate risks and benefits when selecting therapy. GLP-1 receptor agonists delay gastric emptying, raising concerns about perioperative aspiration and mimicking ileus symptoms. Counsel patients on GI side effects, gallbladder disease risks, and rare pancreatitis. Monitor for medication shortages and high costs.

Assess risks of SGLT2 inhibitors, including volume depletion, genital yeast infections, and euglycemic ketoacidosis. Hold therapy during surgery, vomiting, or severe diarrhea. Start SGLT2 inhibitors at an eGFR of ≥ 20 mL/min/1.73 m² for kidney and cardiovascular benefits and continue until dialysis is initiated.

Weigh insurance coverage and prior authorization barriers. Ensure patients understand cost considerations, administration (most GLP-1 receptor agonists are injectable), and potential side effects. Stay updated on evolving guidelines to provide evidence-based, patient-centered diabetes care.

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References

American Diabetes Association Professional Practice Committee. 9. Pharmacologic Approaches to Glycemic Treatment: Standards of Care in Diabetes-2025. Diabetes Care. 2025 Jan 1;48(Supplement_1):S181-S206.
American Diabetes Association Professional Practice Committee. 10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes-2025. Diabetes Care. 2025 Jan 1;48(Supplement_1):S207-S238.
Shin H, Paik JM, Everett BM, et al. Comparative Effectiveness of Individual Sodium-Glucose Cotransporter 2 Inhibitors. JAMA Intern Med. 2025;185(3):302-313.
Perkovic V, Tuttle KR, Rossing P, et al. Effects of Semaglutide on Chronic Kidney Disease in Patients with Type 2 Diabetes. N Engl J Med. 2024;391(2):109-121.