Initial glucose-lowering therapy for diabetes
Recommend initial therapy for diabetes based on patient specific factors, including degree of diabetes control and comorbidities. Initial therapy generally consists of a subset of GLP-1 agonists, SGLT-2 inhibitors and metformin.
Clinical notes
For patients with diabetes not yet on a glucose-lowering agent, this protocol recommends initial therapy. If A1c is elevated but not severely so, monotherapy is reasonable: SGLT-2 if renal failure or heart failure is present, GLP-1 if patient is overweight, SGLT-2 or GLP-1 if there is elevated cardiovascular risk, or metformin otherwise. If A1c is severely elevated, then dual therapy is recommended: GLP-1 and SGLT-2 if patient is overweight and has heart failure or chronic kidney disease, high cardiovascular risk; SGLT-2 and metformin if heart failure or CKD; GLP-1 and metformin if overweight. See figure 9.3 of ADA Diabetes standards of care 2023 for an overall treatment algorithm based on comorbidities and goals.
