The American College of Physicians (ACP) announced updates to the 2012 ACP guideline regarding the use of oral pharmacologic treatment in adults with type 2 diabetes.

The update was prompted following new research evaluating medications for type 2 diabetes and recent Food and Drug Administration (FDA) approvals of new medications.

The guideline was based on a systematic review of randomized, controlled trials and observational studies published through December 2015 on the comparative efficacy of oral medications for type 2 diabetes. The medications studied included metformin, thiazolidinediones, sulfonylureas, dipeptidyl peptidase-4 (DPP-4) inhibitors, and sodium-glucose co-transporter 2 (SGLT-2) inhibitors.

Studied outcomes included intermediate outcomes of HbA1c, weight, systolic blood pressure, and heart rate; all-cause mortality; cardiovascular and cerebrovascular morbidity and mortality; retinopathy, nephropathy, and neuropathy; and harms.

The ACP now recommends that metformin be prescribed to patients with type 2 diabetes when medication is needed to improve glycemic control (Grade: strong recommendation; moderate-quality evidence). “The escalating rates of obesity in the U.S. are increasing the incidence and prevalence of diabetes substantially. Metformin has the added benefit of being associated with weight loss,” said Nitin S. Damle, MD, MS, MACP, president, ACP. Recently, after reviewing published clinical studies, population-based studies, and retrospective case series, the Food and Drug Administration (FDA) concluded that metformin can be safely used in patients with mild renal impairment and in some patients with moderate impairment. 

If a second oral agent is needed to improve high blood sugar, physicians should consider adding either a sulfonylurea, thiazolidinedione, SGLT-2 inhibitor, or DPP-4 inhibitor to metformin (Grade: weak recommendation; moderate-quality evidence). A comparison of benefits and harms with combination therapy led to the ‘weak’ recommendation; combination treatments were also associated with more adverse effects. As the increased cost may not always support the added benefit, the ACP recommends that patients and clinicians discuss the benefits, harms, and costs of additional drugs. 

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The American Academy of Family Physicians has endorsed this guideline.

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