This document provides guidelines for selecting first and second line medication therapies for treating type 2 diabetes. First line therapy includes metformin, weight loss, and increased physical activity. For patients not meeting HbA1c targets, treatment depends on whether the patient has established cardiovascular or kidney disease. For those patients, preferred second line therapies include GLP-1 receptor agonists or SGLT2 inhibitors. For patients without these conditions, preferred second line therapies aim to minimize hypoglycemia and weight gain/promote loss and include DPP-4 inhibitors, GLP-1 receptor agonists, SGLT2 inhibitors, or thiazolidinediones. Basal insulin may be added if further glycemic control is needed. Cost

1. Quick DM Type
II Medication
Selection Guide

2. First Line Therapy

3. First Line Therapy
▪ Metformin
▪ Weight Loss
▪ Increased physical activity
▪ IN the near future it is possible that SGL2 inhibitors may move to First
Line Therapy
▪ If HbA1c is above target then breakdown IF:
▪ Established ASCVD or CKD OR
▪ Without established ASCVD or CKD

4. Established ASCVD or
CKD

5. Established ASCVD or CKD
▪ ASCVD Predominates
▪ GLP-1 RA Either/OR SGLT2i
▪ If further intensification is required
▪ Consider adding other class above, DPP-4i (if not on GLP-Rai)
▪ Basal insulin, Thiazolidinediones (Low Dose), Sulfonylurea (Latest gen with less risk
for hypoglycemia)
▪ IF HF OR CKD Predominates
▪ SGLT2i (check eGFR),if can not tolerate GLP-1 RA
▪ If further intensification is required
▪ DO NOT GIVE Thiazolidines in the setting of HF
▪ Consider DPP-4i (Not Saxagliptin)
▪ Basal insulin, Sulfonylurea (Newer Agents with less chance for hypoglycemia)
▪ SGLT2i- empagliflozin> canagliflozin
▪ GLP-1 RA- liraglutide> semaglutide > exenatide extended release

6. Without established
ASCVD or CKD

7. Without established ASCVD or CKD
▪ Need to minimize hypoglycemia
▪ DPP-4i, GLP-1 RA, SGLT2i2, TZD
▪ If still not at goal add an alterative of one of the above
▪ If still not at goal add basal insulin and Sulfonylurea (Newer Agents with
less chance for hypoglycemia)

8. Without established ASCVD or CKD
▪ Need to minimize weight gain or promote weight loss
▪ Start on a GLP-1 RA either/Or SGLT2i
▪ IF the above is not at goal, consider use the alterative
▪ IF still not at goal and/or can not tolerate SGLT2i add DPP-4i
▪ Be cautious in adding a:
▪ Basal insulin, Thiazolidinediones (Low Dose), Sulfonylurea (Latest gen with
less risk for hypoglycemia)
▪ GLP-1 RA- Semaglutide >liraglutide>dulaglutide>exenatide> lixisenatide

9. Without established ASCVD or CKD
▪ If cost is a major issue:
▪ Thiazolidinediones, Sulfonylurea
▪ IF still not at goal, alternate the above
▪ IF still not at goal add:
▪ Basal insulin OR DPP-4i OR SGLT2i (Costs vary per region)