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ACP 2024 guideline: newer glucose-lowering drugs in type 2 diabetes

This ACP guideline addresses the use of newer pharmacologic agents, including GLP-1 receptor agonists, SGLT2 inhibitors, DPP-4 inhibitors, and GLP-1/GIP combination agents, in adults with type 2 diabetes who have not achieved glycemic goals with metformin or lifestyle measures alone. It focuses on comparative effectiveness and harms for cardiovascular, renal, and mortality outcomes rather than glycemic control alone, reflecting a shift toward outcomes-based prescribing decisions.

ACP2024 editionSummary
Official guidelineNewer Pharmacologic Treatments in Adults With Type 2 Diabetes: A Clinical Guideline From the American College of Physicians. ACP, 2024.
Read the official guideline · Checked for a newer edition on 2026-10-20
We do not reproduce the guideline text — this page is an independent summary.

Who it applies to

Adults with type 2 diabetes being considered for additional pharmacotherapy beyond metformin or initial lifestyle management.

Key recommendations

  • SGLT2 inhibitors are recommended for adults with type 2 diabetes and inadequate glycemic control on metformin or lifestyle therapy alone, particularly to reduce risk of all-cause mortality, cardiovascular mortality, and progression of chronic kidney disease.
    Strong
  • GLP-1 receptor agonists are recommended for adults with type 2 diabetes and inadequate glycemic control, particularly to reduce all-cause mortality and risk of stroke.
    Strong
  • The guideline strongly recommends against adding a DPP-4 inhibitor, based on high-certainty evidence that this class does not reduce morbidity or all-cause mortality compared with continuing metformin or lifestyle therapy alone.
    Strong
  • Choice among newer agents should take into account patient comorbidities, such as preferring SGLT2 inhibitors or GLP-1 receptor agonists in patients with established cardiovascular disease or chronic kidney disease.
  • The guideline emphasizes that evidence for these agents is strongest when considering cardiovascular, renal, and mortality endpoints rather than hemoglobin A1c reduction alone as the primary outcome of interest.
  • Cost, access, and patient preference are highlighted as important factors in the choice between agent classes given substantial price differences between newer and older diabetes medications.
  • The guideline does not strongly favor one newer agent class universally but differentiates recommendations based on specific outcome priorities (mortality, cardiovascular events, or renal protection).

Practice points for students

  • Think of SGLT2 inhibitors and GLP-1 receptor agonists as having the strongest outcome evidence among newer agents, rather than defaulting to DPP-4 inhibitors as an add-on.
  • This guideline frames treatment choice around hard outcomes (mortality, cardiovascular events, renal progression) rather than A1c targets alone, a shift relevant for exam questions on evidence-based prescribing.
  • Patient-specific comorbidities such as cardiovascular disease or chronic kidney disease should guide the choice between SGLT2 inhibitors and GLP-1 receptor agonists.
  • Cost and access barriers are explicitly acknowledged as a limiting factor in real-world implementation of these recommendations.

Condition

Type 2 diabetes

Other guidelines on this topic

Independent educational summary written by the WhiteCoat Pro editorial team with AI assistance and checked by a second AI model. It does not reproduce the guideline text, tables or figures, and it is not affiliated with or endorsed by ACP. It is not medical advice: always read the original guideline before applying it to patients.