PHARMACOLOGIC APPROACHES TO DIABETES TREATMENT: ORAL MEDICATIONS
Faculty:
L. Austin Fredrickson, MD, FACP
L. Austin Fredrickson is an Associate Professor of Internal Medicine at Northeast Ohio Medical University, where he serves as core faculty and teaches diagnostics, therapeutics, clinical skills, and health humanities. He is board-certified in general internal medicine and practices rural primary care. 
Liz Fredrickson, PharmD, BCPS
Liz Fredrickson, PharmD, BCPS, is an Associate Professor of Pharmacy Practice and Pharmaceutical Sciences at the Northeast Ohio Medical University (NEOMED) College of Pharmacy, where she is course director of the Parenteral Products and Basic Pharmaceutics Lab courses.
Pamela Sardo, PharmD, BS
Pamela Sardo, PharmD, BS, is a freelance medical writer and licensed pharmacist. She is the founder and principal at Sardo Solutions in Texas. Pam received her BS from the University of Connecticut and her PharmD from the University of Rhode Island. Pam’s career spans many years in retail, clinics, hospitals, long-term care, Veterans Affairs, and managed health care responsibilities across a broad range of therapeutic classes and disease states.
Abstract
Diabetes mellitus remains a major public health problem as a leading cause of death and micro- and macro-vascular morbidity. The management of diabetes continues to evolve as new research, technologies, and treatments enable enhanced patient care. It is vital for health care providers, including physicians, nurses, and pharmacists, to remain up to date with the newest diabetes care guidelines, which include updates to the pharmacologic management of diabetes mellitus. This course will compare available oral diabetes medications, discussing mechanisms of action, dosing, side effects, and contraindications. The suggested placement of these medications within a therapeutic regimen will be discussed in the context of the updated 2023 American Diabetes Association Standards of Care.
Accreditation Statements
In support of improving patient care, RxCe.com LLC is jointly accredited by the Accreditation CouncilTM for Continuing Medical Education (ACCME®), the Accreditation Council for Pharmacy Education (ACPE®), and the American Nurses Credentialing Center (ANCC®), to provide continuing education for the healthcare team.
This activity was planned by and for the healthcare team, and learners will receive 2 Interprofessional Continuing Education (IPCE) credits for learning and change.
Joint Universal Activity Number: The Joint Accreditation Universal Activity Numbers assigned to this activity are as follows:
Pharmacists: JA4008424-0000-26-044-H01-P
Pharmacy Technicians: JA4008424-0000-26-044-H01-T
Credits: 2 contact hour(s) (0.2 CEU(s)) of continuing education credit.
Credit Types:
IPCE Credits - 2 Credits
AAPA Category 1 Credit™️ - 2 Credits
AMA PRA Category 1 Credit™️ - 2 Credits
Pharmacy - 2 Credits
Type of Activity: Application
Media: Computer-Based Training (i.e., online courses)
Estimated time to complete activity: 2 contact hour(s) (0.2 CEU(s)), including Activity Pre-Test, Post-Test, and Activity Evaluation.
Release Date: April 3, 2026 Expiration Date: April 3, 2029
Target Audience: This educational activity is for Physicians, Physician Assistants, Pharmacists, and Pharmacy Technicians
How to Earn Credit: From April 3, 2026, through April 3, 2029, participants must:
Read the “learning objectives” and “author and planning team disclosures;”
Take the “Educational Activity Pre-Test;”
Study the section entitled “Educational Activity;” and
Complete the Educational Activity Post-Test and Activity Evaluation. The Educational Activity Post-Test will be graded automatically. Following successful completion of the Educational Activity Post-Test with a score of 70% or higher, a statement of participation will be made available immediately. (No partial credit will be given.)
CME Credit: Credit for this course will be uploaded to CPE Monitor® for pharmacists. Physicians may receive AMA PRA Category 1 Credit™️ and use these credits toward Maintenance of Certification (MOC) requirements. Physician Assistants may earn AAPA Category 1 CME credit, reportable through PA Portfolio. All learners shall verify their individual licensing board’s specific requirements and eligibility criteria.
Statement of Need
Type 2 diabetes mellitus is highly prevalent, and beyond lifestyle modification, pharmacologic therapy is often required. Because treatment plans differ and efficacy, mechanism of action, and adverse effect profiles vary, healthcare professionals need guidance. Several reputable professional societies produce evidence-based clinical practice guidelines. Awareness of the standard of care regarding contraindications and place in therapy is also necessary to optimize patient outcomes. This activity aims to address potential gaps in management strategies by reviewing the major oral medication classes used in type 2 diabetes and considering individualized regimens. It also highlights safety considerations and class-specific warnings and emphasizes practical counseling points to support adherence and monitoring, aligning personalized treatment with contemporary guideline-based care.
Learning Objectives: Upon completion of this educational activity, participants should be able to:
Compare and contrast the mechanisms of action of available oral diabetes medications
Describe the side effects and contraindications of oral diabetes medications
Identify when to utilize oral diabetes medications within a therapeutic regimen for patients with Type 2 diabetes mellitus
Recall patient counseling points related to the use of oral diabetes medications
Disclosures
The following individuals were involved in planning, developing, and/or authoring this activity: L. Austin Fredrickson, MD, FACP; Liz Fredrickson, PharmD, BCPS; and Pamela Sardo, PharmD, BS. None of the individuals involved in developing this activity has a conflict of interest or financial relationships related to the subject matter. There are no financial relationships or commercial or financial support relevant to this activity to report or disclose by RxCe.com or any of the individuals involved in the development of this activity.
© RxCe.com LLC 2026: All rights reserved. No reproduction of all or part of any content herein is allowed without the prior, written permission of RxCe.com LLC.
Educational Activity Pre-Test
Which of the following medications is contraindicated for a patient with an eGFR less than 30 mL/min/1.73 m2?
Linagliptin
Metformin
Pioglitazone
Sitagliptin
Possible side effects of SGLT-2 inhibitors include which of the following?
Lactic acidosis, vitamin B12 deficiency, nausea
Upper respiratory tract infections, fractures, headaches
Hypoglycemia, weight gain, dizziness
Nocturia, urinary tract infections, vaginal mycosis
Which of the following classes of oral antidiabetic (OAD) medications work by stimulating the release of insulin from pancreatic β-cells, thereby increasing insulin levels in the blood?
Meglitinides
Alpha-glucosidase inhibitors
Bile acid sequestrants
Amylin analogs
Educational Activity
Pharmacologic Approaches to Diabetes Treatment: Oral Medications
Introduction
The management of Type 2 diabetes mellitus (T2DM) involves a holistic, patient-centered approach that encompasses lifestyle modifications and pharmacologic therapies. While the current American Diabetes Association (ADA) Standards of Care 2023 highlight the benefits of injectable agents for achieving glycemic and weight-loss goals and reducing cardiorenal risks, oral antidiabetic (OAD) medications still have important roles in the care plans of many patients. Numerous classes of OADs are available, each with its unique mechanism of action, efficacy, and safety profile. This course will compare available oral medications for diabetes with a discussion of mechanisms of action, dosing, side effects, and contraindications. The suggested place of these medications within a therapeutic regimen will be discussed in the context of the updated American Diabetes Association Standards of Care in Diabetes 2023 guidelines.
Oral Antidiabetic Medications
Metformin
In previous versions of the ADA guidelines, metformin, brand name Glucophage, was promoted as a first-line agent in managing T2DM.1 While it has fallen slightly out of favor within more recent guideline recommendations, it still offers important benefits for patients with T2DM.3
Mechanism of Action
Metformin is classified as a biguanide and is unrelated pharmacologically to other classes of OAD medications.1,4 Metformin activates the enzyme adenosine monophosphate-activated protein kinase (AMPK), which leads to increased glucose uptake in skeletal muscle and suppressed hepatic glucose production.4 It also decreases the intestinal absorption of glucose and improves insulin sensitivity via increasing peripheral glucose uptake and absorption.4
Pharmacokinetics
While the onset of action of metformin occurs within a few days, the maximum effect can take up to two weeks to occur.4 Metformin has a half-life elimination of ~18 hours in the blood and a fasting bioavailability of 50-60%.4
Dosing
Metformin is available in immediate-release and extended-release tablet formulations.4,5 It is also available as a solution and suspension.6 Dosing for metformin is available in Table 1 below.4,5 Metformin should be taken with or immediately following meals.1,4 Metformin should be dosed starting at the lower end of the range, with doses titrated up slowly to minimize gastrointestinal (GI) side effects.4 If doses greater than 2 grams per day are required, it is recommended to divide the total daily dose (TDD) into three doses (if using the immediate-release formulation) or two doses (extended-release formulation) to minimize GI side effects.4 Between 5 and 10% of patients will not tolerate metformin therapy despite low and slow dose titrations.4
Table 1
Metformin Dosing
| Immediate release4 | |||
Initial dose | Dose adjustments | Maintenance dose | Maximum dose |
500 mg once or twice daily OR 850 mg once daily | Increase by 500 mg or 850 mg every 7 days | 1 gram twice daily OR 850 mg twice daily | 2.55 grams/day |
| Extended release5 | |||
Initial dose | Dose adjustments | Maintenance dose | Maximum dose |
| 500 mg to 1 gram per day | 500 mg every 7 days | 500-2000 mg per day | 2 grams/day |
Metformin is renally excreted and will accumulate in patients with renal impairment.1 Patients with an eGFR ≥ 60 mL/min/1.73 m2 do not require dose adjustments; however, renal function should be monitored at least annually.5 Patients with an eGFR between 45 and 60 mL/min/1.73 m2 should have increased renal monitoring, but do not require dose adjustments.5 Initiation of metformin is typically not recommended for patients with an eGFR between 30 and 45 mL/min/1.73 m2.5 Patients already taking metformin should reduce the dose to 500 mg twice daily and closely monitor renal function. Metformin is contraindicated at eGFR less than 30 mL/min/1.73 m2.4,5
Dosing recommendations vary by the degree of hepatic impairment.4
Child-Turcotte-Pugh Class A: No dose adjustment needed
Child-Turcotte-Pugh Class B: 500 mg once daily with increases of less than or equal to 500 mg per day every 30 days
Child-Turcotte-Pugh Class C: Avoid use
Side Effects and Monitoring
The most common side effects of metformin include gastrointestinal symptoms such as nausea, diarrhea, and abdominal discomfort.4 Diarrhea is more common with the immediate-release formulation compared to the extended-release (53% vs 10%).4 Patients should be counseled that these symptoms can often be minimized by taking the medication with food, starting with a lower dose, and gradually titrating up.4 Other potential side effects include vitamin B12 deficiency and lactic acidosis.4 B12 levels should be monitored if there is a suspected deficiency and otherwise checked every 1-2 years.1,4 Cases of lactic acidosis are rare and often precipitated by acute kidney injury or severe illnesses; risk factors include renal impairment, acute congestive heart failure, hepatic impairment, and excessive alcohol consumption.1 Hemoglobin A1C (A1C) levels should be monitored twice yearly in patients with stable glycemic control and at least quarterly in those not meeting goals.4,5,7
Drug Interactions
Metformin can interact with a variety of medications.
Contraindications and Warnings
Metformin is contraindicated in patients with severe renal impairment (eGFR <30 mL/min/1.73 m2), acute or chronic metabolic acidosis, and/or hypersensitivity to metformin.4,5 Current guidelines also recommend holding metformin prior to the administration of iodinated contrast in those with acute kidney injury, severe chronic kidney disease, or risk factors for lactic acidosis.1,4,5 It can be resumed 48 or more hours later once normal kidney function is noted.1,4,5
Pause and Ponder A patient with Type 2 diabetes requires additional therapy beyond metformin. How do you determine the most appropriate oral medication? |
Patient Case
A 75-year-old woman with T2DM and CKD (eGFR 40) is started on a sulfonylurea. She lives alone and has had two recent episodes of dizziness.
Questions:
Which sulfonylurea would be the safest for this patient?
What is the biggest risk associated with this drug class in older adults?
How would you counsel this patient?
Answers:
Glipizide is preferred in renal impairment
The major risk is hypoglycemia, especially in elderly patients
Must counsel on recognizing and managing low blood sugar; e.g., counsel the patient to recognize symptoms of hypoglycemia, such as dizziness, tremor, sweating, rapid heartbeat, or headache.
Sulfonylureas
There are two generations of sulfonylurea medications.1 First-generation agents include chlorpropamide, tolbutamide, and tolazamide;1 second-generation agents include glyburide, glipizide, and glimepiride.1,8,9,10 Due to their side effect profiles and lower efficacy rates, first-generation agents are rarely used.1
Mechanism of Action
Sulfonylureas work by binding a sulfonylurea receptor (SUR1) and stimulating insulin release from β-cells in the pancreas.8-10 This reduces glucose output from the liver and increases insulin sensitivity at peripheral sites.8-10
Pharmacokinetics
Table 2 details the pharmacokinetic profiles of glipizide, glimepiride, and glyburide.8-10
Table 2
Pharmacokinetic Profiles of Sulfonylureas
| Agent | Duration | Metabolism | Half-life (hrs) |
| Glipizide8,11 | 12-24 hours | 90-100% | 2-5 |
| Glimepiride9,12 | 24 hours | Hepatic oxidation via CYP2C9 | 5-9 |
| Glyburide10,13,14 | ≤24 hours | Hepatic (forms metabolites) | DiaBeta: 10 Glynase PreTab: 4 |
Dosing
The sulfonylureas are available in immediate and extended-release formulations.1 Glipizide is available as 2.5 mg, 5 mg, and 10 mg tablets.8,11 Glimepiride is available as 1 mg, 2 mg, and 4 mg tablets.9,12 Glyburide is available as conventional tablets (DiaBeta) and micronized tablets (Glynase® PresTab® PresTab).13,14 Dosing strategies for the various sulfonylureas are listed in Table 3. Glipizide should be taken 30 minutes prior to the first meal of the day.8,11 Glimepiride and glyburide should be taken with the first meal.9,10 Sulfonylureas are equally effective in lowering blood glucose when given at equipotent doses.1
Table 3
Sulfonylurea Dosing
| Agent | Initial Dose | Dose Adjustment | Maintenance Dose | Maximum Dose |
Glipizide (IR)8 (Glucotrol and Glucotrol XL)11 | 2.5-5 mg once daily; 2.5 mg for patients at risk of hypoglycemia; 10 mg twice daily in patients with severe hyperglycemia | Increase by 2.5 to 5 mg every 1-4 weeks if needed | 2.5-10 mg/day | 20 mg/day |
| Glipizide (ER)15 | 2.5 to 5 mg once daily | Increase by 2.5 to 5 mg every 1-4 weeks as needed | 5-10 mg/day | 20 mg/day |
Glimepiride9,12 (Amaryl®) | 1-2 mg once daily; 1 mg once daily for patients close to glycemic goals; 4 to 8 mg in patients with severe hyperglycemia | Increase by 1 to 2 mg every 1-4 weeks | 2-4 mg per day | 8 mg per day |
Glyburide (DiaBeta) Conventional tablets13 | 1.25 to 5 mg once daily; Use lower doses in patients close to glycemic goals | Increase by ≤2.5 mg every 1-4 weeks | 2.5-10 mg/day in 1-2 divided doses | 20 mg day in 1-2 divided doses |
Glipizide has inactive metabolites and is thus the preferred sulfonylurea in patients who have renal impairment.8 Patients with hepatic impairment should start at the 2.5 mg dose of glipizide IR or ER, and maintenance dosing should be conservative to avoid hypoglycemia.8,11 There are no dose adjustments recommended for glyburide in hepatic impairment.8,11 The following dose adjustments are recommended for sulfonylureas.8-10 (See Table 4.)
Table 4
Renal and Hepatic Dose Adjustments of Sulfonylureas
| Glipizide | eGFR >50 | eGFR 10-<50 | eGFR <10 | Hemodialysis |
| No dose adjustment needed | 2.5 mg daily and titrate cautiously to a maximum of 20 mg/day | Avoid use if possible | Use with caution | |
| Glimepiride | eGFR > 60 | eGFR 15 to <60 | eGFR <15 | Hemodialysis |
| No dose adjustment needed | Initiate at low dose and titrate cautiously | Avoid use | Avoid use | |
| Glyburide | eGFR ≥60 | eGFR <60 | Hemodialysis | |
| No dose adjustment needed | Avoid due to its long duration of action | Avoid use |
Side Effects and Monitoring
Sulfonylureas are associated with many side effects, including hypoglycemia, weight gain, and gastrointestinal disturbances, including nausea, vomiting, diarrhea, and constipation.8-10 Glyburide is associated with a higher risk of hypoglycemia due to its active metabolite.1 All patients taking sulfonylureas should be monitored for signs and symptoms of hypoglycemia (fatigue, increased hunger, sweating, numbness in extremities) and counseled on managing low blood sugars.1,8-10 Blood glucose levels, renal function, liver function, and body weight should be regularly monitored.8-10 Hemoglobin A1C (A1C) levels should be monitored twice yearly in patients with stable glycemic control and at least quarterly in those not meeting goals.8-10
Drug Interactions, Contraindications, and Warnings
Contraindications to using sulfonylureas include a history of hypersensitivity to sulfonylureas or sulfonamide derivatives, type 1 diabetes, and diabetic ketoacidosis.8-10 Sulfonylureas with active metabolites and long durations of action should be avoided in elderly patients due to the risk of hypoglycemia.1,8-10 For these patients, glipizide may be the best choice. Caution is also warranted for patients undergoing bariatric surgery and a deficiency of glucose-6-phosphate dehydrogenase (G6PD).8-10 Additionally, patients in a stress-related state (such as fever or trauma) should discontinue therapy and resume once the stress state is passed.8-10
Thiazolidinediones
Pioglitazone is an FDA-approved thiazolidinedione (TZD) as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus in multiple clinical settings.16
Mechanism of Action
Thiazolidinediones enhance insulin sensitivity in fat, liver, and muscle tissue.1 They exert their effects via binding the peroxisome proliferator-activated receptor-gamma (PPAR gamma) in fat and vascular cells.1,16 Activation of these receptors increases the production of gene products involved in glucose and lipid metabolism in the liver, muscle, and adipose tissue.16 PPAR-gamma is also located in renal collecting tubules, which have effects on fluid retention.16
Pharmacokinetics
Pioglitazone has a delayed onset of action, and it can take several weeks to months for glucose control to be achieved.16 This is an important counseling point for patients who may notice minimal changes to their blood glucose levels at the start of therapy.16 It is metabolized via CYP2C8 and CYP3A4 to both active and inactive metabolites.16 Its half-life elimination is 3-7 hours for the parent drug and 16-24 hours for its metabolites.16
Dosing
Pioglitazone is available as a 15 mg, 30 mg, and 45 mg tablet.16 The initial dose is 15 to 30 mg once daily, which may be administered without regard to meals.16 This can be titrated in increments of 15 mg per day every 4-12 weeks to a maximum dose of 45 mg/day.16 Pioglitazone is also available in a combination form with either metformin or glimepiride. In patients with mild-severe renal impairment, no pioglitazone dose adjustment is needed.8 Pioglitazone use should be avoided in patients with cirrhosis.16
Side Effects and Monitoring
There are several adverse reactions associated with TZDs. First, they may increase the risk of bladder carcinoma.16 This risk is both dose and time-related, with a delayed onset.16 Most cases occur with long-term use and high-dose exposure.16 Major risk factors include more than 2 years duration, European ethnicity, Caucasian race, and a prior history of bladder cancer.16 TZDs can also increase the risk of bone fractures.16 The absolute risk found with pioglitazone use was 1.6-4.9% absolute risk increase.16 The onset of fractures is delayed, with a greater risk after 2 years of therapy.16 The risk is also higher in elderly patients, those with prior stroke, and those with retinopathy.16
A third major adverse reaction is an increased risk of cardiac failure and dose-dependent edema.16 These symptoms are reversible after discontinuation.16 The onset is intermediate in length, typically within the first few weeks of therapy.16 Patients at greater risk include those with pedal edema or on treatment with loop diuretics, those with cardiovascular disease or hypertension, those on medications associated with fluid retention, older adults (>70 years old), those with a history of heart failure, diabetes for more than 10 years, and those with chronic kidney disease.16 Finally, patients may be at risk of hepatic failure, though this risk is higher with older TZDs than pioglitazone.16 This delayed effect occurs 1-7 months after starting therapy.16
Other side effects (with associated incidences) include hypoglycemia (27%), upper respiratory tract infections (13%), headache (9%), and back pain (6%).16 Patients should be monitored closely for signs and symptoms of heart failure, including rapid weight gain, dyspnea, and edema).16 Serum glucose and A1C levels should be monitored.16 Additionally, liver enzymes (ALT, AST, and alkaline phosphatase) should be drawn prior to initiation in all patients, with routine monitoring recommended in patients with liver disease.16 TZDs may lead to the resumption of ovulation in anovulatory, pre-menopausal women.1 These individuals should be counseled on pregnancy prevention.1
Contraindications and Warnings
Thiazolidinediones should not be used in patients with heart failure (NYHA Class 3 or 4) or a history of bladder cancer.16 They are also contraindicated in patients with hypersensitivity to TZDs.16
DPP4-Inhibitors
Four Food and Drug Administration (FDA)-approved dipeptidyl peptidase-4 (DPP-4) inhibitors are sitagliptin (Januvia), alogliptin (Nesina), saxagliptin (Onglyza), and linagliptin (Tradjenta).17-20 All agents have similar efficacy.1
Mechanism of Action
Dipeptidyl peptidase-4 inhibitors block the dipeptidyl peptidase-4 enzyme, resulting in prolonged active incretin levels.17-20 Incretins (GLP-1 and GIP) work to regulate glucose homeostasis by increasing the synthesis of insulin and its release and are normally inactivated by the DPP-4 enzyme.17-20 Patients with T2DM are deficient in GLP-1.1 DPP-4 inhibitors also decrease glucagon secretion, leading to decreased hepatic glucose production.17-20
Pharmacokinetics
The pharmacokinetic profiles of the DPP-4 inhibitors are presented in Table 5.
Table 5
Pharmacokinetic Profiles of the DPP-4 Inhibitors17-20
| Agent | Metabolism | Half-life | Time to peak |
| Alogliptin | Not extensive; minor metabolism via CYP2D6 and CYP3A4 | 21 hours | 1-2 hours |
| Linagliptin | Not extensive | 11 hours | 1.5 hours |
| Saxagliptin | Hepatic via CYP3A4/5 | 2.5 hours | 2 hours |
| Sitagliptin | Not extensive; minor metabolism via CYP3A4 and 2C8 | 12.4 hours | 1-4 hours |
Dosing
Sitagliptin is available in 25 mg, 50 mg, and 100 mg tablets.17 Alogliptin comes in 6.25 mg, 12.5 mg, and 25 mg tablets.18 Linagliptin is available in 5 mg tablets, and saxagliptin in 2.5 mg and 5 mg tablets.19,20 The DDP-4 inhibitors can be taken without food. Dosing is provided in Table 6.
Table 6
DPP-4 Inhibitor Dosing17-20
| Agent | Initial Dose | Maximum Dose |
| Alogliptin | 25 mg once daily | 25 mg once daily |
| Linagliptin | 5 mg once daily | 5 mg once daily |
| Saxagliptin | 2.5-5 mg once daily | 5 mg once daily |
| Sitagliptin | 100 mg once daily | 100 mg once daily |
Linagliptin does not require dose adjustments for renal or hepatic impairment, and saxagliptin does not require dose adjustments for hepatic impairment.19,20 No dose adjustments are recommended for alogliptin or sitagliptin regarding hepatic impairment, but caution is warranted.17,18 Table 7 provides renal dose adjustments recommended for other DPP-4 inhibitors.17,18
Table 7
DPP-4 Inhibitor Renal Dose Adjustments
| Sitagliptin | eGFR ≥45 | eGFR ≥30-<45 | eGFR <30 | Hemodialysis |
| None | 50 mg once daily | 25 mg once daily | 25 mg once daily | |
| Alogliptin | CrCl ≥60 | CrCl ≥30 and <60 | CrCl <30 | Hemodialysis |
| None | 12.5 mg once daily | 6.25 mg once daily | 6.25 mg once daily | |
| Saxagliptin | eGFR ≥45 | eGFR <45 | ESRD with hemodialysis | |
| None | 2.5 mg once daily | 2.5 mg once daily post-dialysis |
Side Effects and Monitoring
Dipeptidyl peptidase-4 inhibitors are generally well-tolerated.1 Headache and upper respiratory tract infections are possible but uncommon.1 Five major safety concerns related to DPP-4 inhibitor use include arthralgia, dermatologic reactions, heart failure, hypersensitivity reactions, and pancreatic issues.17-20
Severe cases of arthralgia have been linked to the use of DPP-4 inhibitors.17-20 The onset is variable and can occur within 1 day or years after treatment starts.17-20 The major risk factor is the duration of therapy; however, data are conflicting.17-20 A second concern is the development of dermatologic reactions, including bullous pemphigoid.17-20 Severe cutaneous adverse reactions (SCARs), such as Stevens-Johnson syndrome, have also been reported.17-20 The onset of bullous pemphigoid is typically around 6 months after starting therapy, while other delayed hypersensitivity reactions may occur days to weeks after starting a DPP-4 inhibitor.17-20 Risk factors include older age and males may be at an increased risk.17-20
Heart failure is a potential risk associated with DPP-4 inhibitor use, specifically with saxagliptin and alogliptin.17-20 Current ADA guidelines allow consideration of DPP-4 inhibitor use in patients with heart failure, but these agents are not preferred in this patient population.17-20 The main risk factor is pre-existing heart failure or having risk factors for heart failure.17-20
Hypersensitivity reactions, including anaphylaxis and angioedema, are possible with DPP-4 inhibitor use.17-20 These are non-dose-related immunologic reactions with varied onset.17-20 Often, these occur within the first three months of therapy.17-20 Risk factors include the concomitant use of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, or p-glycoprotein inhibitors, hereditary angioedema, or a history of angioedema with another DPP-4 inhibitor.17-20
A final, major concern is the occurrence of acute pancreatitis, which includes hemorrhagic pancreatitis, necrotizing pancreatitis, and chronic pancreatitis.17-20 Patients with a history of pancreatitis, acute pancreatitis, or risk factors for pancreatitis are at a greater risk of experiencing this.17-20
Patients taking a DPP-4 inhibitor should have serum glucose levels monitored.17-20 Renal function should be evaluated prior to starting one of these agents and then periodically throughout the treatment period.17-20 Patients should be monitored for signs and symptoms of heart failure, hypersensitivity reactions, pancreatitis, and blistering or erosions.17-20 A1C should be monitored based on the patient’s level of glycemic control.17-20
Contraindications and Warnings
Dipeptidyl peptidase-4 inhibitors are contraindicated in patients with a history of serious hypersensitivity to these agents.17-20 Caution is warranted in patients with prior bariatric surgery.17-20
SGLT-2 Inhibitors
There are five FDA-approved sodium-glucose cotransporter 2 (SGLT-2) inhibitors, including bexagliflozin (Brenzavvy®), canagliflozin (Invokana®), dapagliflozin (Farxiga®), empagliflozin (Jardiance®), and ertugliflozin (Steglatro®).21-25
Mechanism of Action
Sodium-glucose cotransporter 2 is a transporter responsible for the reabsorption of most glucose in the kidneys.21-25 Sodium-glucose cotransporter 2 inhibitors work by blocking this transporter, thereby reducing renal glucose reabsorption and increasing urinary glucose excretion.21-25 This mechanism is independent of insulin and occurs whenever plasma glucose levels are elevated, whether during fasting or the postprandial state.1
Pharmacokinetics
Table 8 below details the pharmacokinetic profiles of the SGLT-2 inhibitors.21-25
Table 8
Pharmacokinetic Profiles of the SGLT-2 Inhibitors21-25
| Agent | Metabolism | Half-life | Time to peak |
Bexagliflozin (Brenzavvy) | Primarily through UFT1A9 and less through CYP3A4 to inactive metabolites | 12 hours | 2-4 hours (5 hours if taken with a full-fat, high-calorie meal) |
Canagliflozin (Invokana) | O-glucuronidation by UGT1A9 and UGT2B4 to two inactive metabolites; minor oxidative metabolism (~7%) through CYP3A4 | 10.6 hrs (100 mg dose) 13.1 hrs (300 mg dose) | 1-2 hours |
Dapagliflozin (Farxiga) | O-glucuronidation by UGT1A9 and UGT2B4 to two inactive metabolites; minor oxidative metabolism (~7%) through CYP3A4 | 12.9 hours | 2 hours |
Empagliflozin (Jardiance) | Primarily through glucuronidation by UGT2B7, UGT1A3, UGT1A8, and UGT1A9 to minor metabolites | 12.4 hours | 1.5 hours |
| Ertugliflozin | Primarily by UGT1A9 and UGT2B7-mediated O-glucuronidation to metabolites that are inactive at clinically relevant concentrations | 16.6 hours | 1 hour fasting, 2 hours with a high-fat, high-calorie meal |
Dosing
Sodium-glucose cotransporter 2 inhibitors are dosed once daily and may be taken with or without food in the morning. Dosing strategies are provided in Table 9 below.21-25
Table 9
Dosing Strategies for SGLT-2 Inhibitors21-25
| Agent | Initial Dose | Maximum Dose |
| Bexagliflozin | 20 mg once daily in the morning | 20 mg once daily |
| Canagliflozin | 100 mg once daily prior to the first meal of the day | 300 mg once daily (after 4-12 weeks of therapy) |
| Dapagliflozin | 5 mg once daily | 10 mg once daily after 4-12 weeks |
| Empagliflozin | 10 mg once daily | 25 mg once daily after 4-12 weeks |
| Ertugliflozin | 5 mg once daily | 15 mg once daily after 4-12 weeks |
Bexagliflozin is not recommended for patients with an eGFR <30 mL/min/1.73 m2 and is contraindicated in patients on dialysis.21 Use is also not recommended for patients with severe hepatic impairment.21 Canagliflozin requires a dose adjustment to 100 mg once daily at an eGFR of 30 to <60 mL/min/1.73 m2.22 Under 30 mL/min/1.73 m2, patients with urinary albumin excretion >300 mg/day should not start therapy, but may continue 100 mg daily.22 Those with ≤300 mg/day should not start therapy.22 At an eGFR <25 mL/min/1.73 m2, the manufacturer does not recommend the use of dapagliflozin.23 Empagliflozin is not recommended under an eGFR of 30 mL/min/1.73 m2.24 Ertugliflozin is not recommended under an eGFR of < 45 mL/min/1.73 m2.25
Side Effects and Monitoring
The most common side effects of SGLT-2 inhibitors are endocrinal and genitourinary in nature.21-25 Patients may experience increased LDL cholesterol and increased thirst.21-25 Additionally, diuresis (including nocturia and polyuria), urinary tract infections, and vaginal mycosis are possible.1,21-25 Symptomatic hypotension may be seen in patients with a lower blood pressure at baseline or an eGFR <60 mL/min/1.73m2.1 Renal function should be closely assessed, and patients should be monitored for genital mycotic infections and urinary tract infections.21-25
Other safety concerns of note include ketoacidosis, amputations, and fractures.1 The overall risk of ketoacidosis, as reported in meta-analyses, is small.1 Patients should be encouraged to remain hydrated throughout treatment.1 In a cardiovascular (CV) outcomes trial, canagliflozin was found to increase the risk of both bone fractures and lower-limb amputations; such fractures may result from falls due to orthostatic hypotension.1 Cases of Fournier gangrene have also been associated with SGLT-2 inhibitor use.1
Contraindications
Sodium-glucose cotransporter 2 inhibitors are contraindicated in patients on dialysis or with any hypersensitivity to SGLT-2 inhibitors.21-25 In patients with renal impairment, there is also an increased risk of hypotension because of intravascular depletion.21-25 Patients should be advised to drink plenty of water while taking SGLT2 inhibitors to prevent dehydration. They should also be instructed to report any symptoms of urinary tract infections or genital yeast infections to their healthcare provider.21-25
Older adults and those on antihypertensive agents are also at a greater risk of hypotension.21-25 Sodium-glucose cotransporter 2 inhibitors may increase the risk of lower-limb amputations, and other risk factors that include prior amputation, peripheral vascular disease, and neuropathy. These risk factors should be weighed against the benefits of therapy before starting one of these agents. 21-25
GLP-1 Receptor Agonists
Semaglutide, in oral form, has received FDA approval as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus.26 It is also approved to reduce the risk of major adverse cardiovascular events in adults with type 2 diabetes mellitus who are at high risk for these events.26 Review the full prescribing information for comprehensive information regarding safety, efficacy, and dosing titration.
Mechanism of Action
Semaglutide selectively binds to and activates the GLP-1 receptor.26 GLP-1 is a hormone that has multiple actions on glucose. It stimulates insulin secretion and lowers glucagon secretion.26 The mechanism also involves delayed gastric emptying during the early postprandial phase.26
Pharmacokinetics
Semaglutide exposure increases in a dose-proportional manner.26 Steady state is achieved following four to 5 weeks of oral administration. Semaglutide elimination half-life is approximately one week. It remains in circulation for about 5 weeks after the last dose.26
Dosing
The Rybelsus brand is available in 3 mg, 7 mg, and 14 mg tablets.26 The Ozempic brand is available in 1.5 mg, 4 mg, and 9 mg tablets. They are not substitutable on a mg-per-mg basis.26 The prescribing information indicates that the lowest doses are ineffective for glycemic control.26 Patients should be counseled to take semaglutide orally once daily in the morning on an empty stomach with no more than 4 ounces of water.26 It should not be taken with other liquids.26 Wait 30 minutes before eating. Dose escalation should occur slowly to achieve and maintain glycemic control and to minimize side effects.26
Side Effects and Monitoring
The most common adverse reactions (incidence ≥5%) are nausea, abdominal pain, diarrhea, decreased appetite, vomiting, and constipation.26 Monitor renal function in patients reporting adverse reactions that could lead to volume depletion.26 Discontinue if hypersensitivity reactions occur. Due to delayed gastric emptying, consider increasing clinical or laboratory monitoring when co-administered with other oral medications that have a narrow therapeutic index.26 Because rapid improvement in glucose control may temporarily worsen diabetic retinopathy, patients with a history of diabetic retinopathy should be monitored for progression.26 Data on use in pregnancy are insufficient to evaluate. Use in pregnancy only if the benefit justifies the risk to the fetus.26
Contraindications
Semaglutide is contraindicated in individuals with a personal or family history of medullary thyroid carcinoma or in patients with Multiple Endocrine Neoplasia syndrome type 2.26
Other Oral Agents
Other OAD medications are not often used but may benefit specific patient subsets. These include meglitinides, alpha-glucosidase inhibitors, bile acid sequestrants, amylin analogs, and bromocriptine. These agents will not be discussed in detail.
Alpha-glucosidase inhibitors (acarbose and miglitol) work by competitively inhibiting maltase, isomaltase, sucrase, and glucoamylase in the small intestine, which delays the breakdown of complex carbohydrates.1 This results in reduced postprandial glucose levels.1 These agents only moderately lower A1C levels and are associated with many GI side effects.1
Meglitinides include nateglinide and repaglinide.1 These agents work by stimulating the release of insulin from pancreatic β-cells, thereby increasing insulin levels in the blood; they have both a faster onset and shorter duration compared to sulfonylureas.1 They may reduce A1C levels by 0.8-1%, and major side effects include weight gain and hypoglycemia.1
Colesevelam is a bile acid sequestrant approved for treating T2DM. Its mechanism of action in relation to DM is unclear.1 Patients needing small decreases in A1C and LDL-C lowering may benefit from its use.1
Bromocriptine is a dopamine receptor agonist that stimulates dopamine receptors in the brain.1 It lowers blood glucose levels modestly, and the mechanism by which it does so is unknown.1
Pramlintide is an injectable analog of amylin.1 Amylin is a neurohormone secreted from beta-cells along with insulin and plays a key role in glucose regulation.1 It may lower A1C levels from 0.4-0.5% and is typically used in patients with T1DM as adjunctive therapy.1
Choice of Glucose-Lowering Therapy
According to ADA guidelines, the management of T2DM typically begins with lifestyle modifications, such as exercise and diet changes.3 However, pharmacologic therapy is often needed to achieve glycemic control.3 When considering pharmacologic therapy, the ADA recommends a patient-centered approach that considers a patient's need for cardiorenal protection, glycemic control, and weight loss and balances this with personal preferences and medical profiles.3 Pharmacologic agents that assist in these treatment goals, including combination therapies, should be started at the time of diagnosis.3
Combination Therapy
The ADA guidelines recommend initial combination therapy for patients with an A1C level that is 1.5-2% above their target goal.3 Various trials have demonstrated the efficacy of initial combination therapy to achieve glycemic targets more quickly and the use of later combination therapy to ensure a longer durability of glycemic control.3 For example, in the VERIFY trial, initial combination therapy with metformin and vildagliptin was found to be superior to the sequential addition of medications.27
Glycemic Control
Reductions in A1C levels associated with the major OAD medications are presented in Table 10.1 Metformin, sulfonylureas, TZDs, and SGLT-2 inhibitors have high glucose-lowering efficacy.3 DPP-4 inhibitors have intermediate glucose-lowering efficacy.3
Table 10
OAD Medication A1C Level Reductions
| Agent | A1C Reduction |
| Metformin | 1.5-2% |
| Sulfonylureas | 1.5-2% |
| TZDs | 1-1.5% |
| DPP-4 Inhibitors | 0.5-0.9% |
| SGLT-2 Inhibitors | 0.5-1%a |
| Semaglutide-oral | 1.0-1.4% |
a: More efficacious in patients with higher baseline A1C levels
Weight Effects
Oral antidiabetic medications can also be compared based on their effects on weight. SGLT-2 inhibitors can cause moderate weight loss.3 Metformin may lead to modest weight loss but is generally weight-neutral.3 Table 11 presents the OAD medications' effects on weight.
Table 11. OAD Medication Effects on Weight
| Agent | Effect on Weight |
| Metformin | Weight neutral-modest weight loss (2-3 kg) |
| Sulfonylureas | Weight gain (1-2 kg) |
| TZDs | Weight gain (dose-related) |
| DPP-4 Inhibitors | Weight neutral |
| SGLT-2 inhibitors | Weight loss (intermediate) |
| Semaglutide-oral | Weight loss (intermediate) |
Hypoglycemia
The risk of hypoglycemia should be considered when selecting an OAD medication. Table 12 compares the agents in this regard. Sulfonylureas are the only agents with a risk of hypoglycemia when used as monotherapy.3
Table 12
OAD Risk of Hypoglycemia
| Agent | Hypoglycemia Risk |
| Metformin | Low risk |
| Sulfonylureas | High risk |
| TZDs | Low risk |
| DPP-4 Inhibitors | Low risk |
| SGLT-2 inhibitors | Low risk |
| Semaglutide-oral | Low risk |
Cardiovascular and Renal Protection
Current ADA guidelines place an emphasis on selecting therapies that reduce cardiorenal risk in patients with T2DM and an established or high risk of atherosclerotic cardiovascular disease, heart failure, and/or chronic kidney disease (CKD).3 Table 13 compares available OAD medications in this regard.3 Metformin may reduce the risk of cardiovascular events.3 Many trials have supported the use of specific SGLT2 inhibitors for the reduction of cardiovascular events in patients with T2DM.3 Guidelines now recommend the use of SGLT2 inhibitors in patients in need of cardiovascular benefits.3,28
Table 13
Cardiorenal Effects
| Agent | Effect on MACE | HF | Progression of CKD |
| Metformin | Potential benefit | Neutral | Neutral |
| Sulfonylureas | Neutral | Neutral | Neutral |
| SGLT-2 inhibitors | Benefit: canagliflozin and empagliflozin | Benefit: canagliflozin, dapagliflozin, empagliflozin, and ertugliflozin | Benefit: canagliflozin, dapagliflozin, empagliflozin |
| DPP-4 inhibitors | Neutral | Neutral | Neutral |
| TZDs | Potential benefit (pioglitazone) | Increased risk | Neutral |
| Semaglutide-oral | Benefit | Benefit | Benefit |
Cost
Finally, given the rising cost of diabetes medications, the price of OAD medications, and a patient’s ability to afford and access these medications, should be considered prior to initiating a regimen. Table 14 provides a cost comparison of these medications.3
Table 14
Cost Comparison of OAD
| Agent | Cost |
| Metformin | Low |
| SGLT-2 inhibitors | High |
| DPP-4 inhibitors | High |
| TZDs | Low |
| Sulfonylureas | Low |
| Semaglutide, oral | High |
Summary
The management of Type 2 diabetes mellitus (T2DM) involves a holistic, patient-centered approach that encompasses lifestyle modifications and pharmacologic therapies.3 Within the current American Diabetes Association (ADA) Standards of Care 2023 guidelines, OAD medications have important roles in many patients' care plans. Numerous classes of OADs are available, each with its unique mechanism of action, efficacy, and safety profile. Healthcare providers should be knowledgeable about these medications and the considerations for adding them to a T2DM therapeutic regimen.
References
Trujillo J, Haines S. Diabetes Mellitus. In: DiPiro JT, Yee GC, Haines ST, Nolin TD, Ellingrod VL, Posey L. eds. DiPiro’s Pharmacotherapy: A Pathophysiologic Approach, 12th Edition. McGraw Hill; 2023.
Centers for Disease Control and Prevention. National Diabetes Statistics Report. CDC. Last updated on March 11, 2026. Accessed April 2, 2026. https://www.cdc.gov/diabetes/php/data-research/?CDC_AAref_Val=https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf
Standards of Care in Diabetes 2023. American Diabetes Association. Diabetes Care. 2023;46(1). Accessed April 2, 2026. https://diabetesjournals.org/care/issue/46/Supplement_1
METFORMIN HCL tablet. Prescribing Information. Ascend Laboratories, LLC. Updated February 7, 2017. Accessed April 2, 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=2d98aea3-35ba-447a-b88f-a5a20b612b2f#:~:text=The%20magnitude%20of%20the%20decline,plasma%20glucose%20and%20glycosylated%20hemoglobin
METFORMIN tablet, extended release. Prescribing Information. Ingenus Pharmaceuticals, LLC. Updated December 5, 2025. Accessed April 1, 2026. https://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=49a0b5c2-ebaf-4c4c-905f-dfd1962ac647
Christofides EA. Practical Insights Into Improving Adherence to Metformin Therapy in Patients With Type 2 Diabetes. Clin Diabetes. 2019;37(3):234-241. doi:10.2337/cd18-0063
ElSayed NA, Aleppo G, Aroda VR, et al. 6. Glycemic Targets: Standards of Care in Diabetes-2023. Diabetes Care. 2023;46(Suppl 1):S97-S110. doi:10.2337/dc23-S006
GLIPIZIDE- glipizide-tablets tablet. Prescribing Information. Graviti Pharmaceuticals Private Limited. Updated March 11, 2026. Accessed April 2, 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=baa43a13-383a-46ee-a2c9-f287150465fe
GLIMEPIRIDE- glimepiride tablet. Prescribing Information. Micro Labs Limited. Updated May 12, 2025. Accessed April 2, 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=60e9397e-83b9-489e-9683-6f87e458bbaa
GLYBURIDE tablet. Prescribing Information. Amneal Pharmaceuticals of New York LLC. Updated December 27, 2019. Accessed April 2, 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=5c391b11-68e9-4040-8408-56b43ee853f5Updated
GLUCOTROL XL- glipizide tablet, extended release. Prescribing Information. Roerig. Updated April 2, 2025. Accessed April 2, 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=eed99b60-d043-4249-9b2a-f05e46fb588d
GLIMEPIRIDE 3 MG- glimepiride tablet. Prescribing Information. Lifsa Drugs LLC. Updated August 20, 2024. Accessed April 2, 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=51157849-7990-4a8b-ae50-eda1baf93cfa#section-11.1
Diaßeta® (glyburide) Tablets. Prescribing Information. sanofi-aventis U.S. LLC. 2009. Accessed April 2, 2026. https://www.accessdata.fda.gov/drugsatfda_docs/label/2009/017532s030lbl.pdf
GLYNASE- glyburide tablets. Glynase® PresTab®. Prescribing Information. Pharmacia & Upjohn Company LLC. Revised August 2023. Accessed April 2, 2026. https://labeling.pfizer.com/showlabeling.aspx?id=597#:~:text=DESCRIPTION,10%20Aluminum%20Lake.
GLIPIZIDE tablet, film coated, extended release. Prescribing Information. Rising Pharma Holdings, Inc. Updated January 17, 2026. Accessed April 2, 2026. https://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=0ffe361a-c99b-4f68-a7e2-a67a71c0c496#:~:text=GLIPIZIDE%20extended%2Drelease%20tablets%2C%20for,%2Ddiabetic%20medications%20(5.1)
PIOGLITAZONE tablet. Prescribing Information. Carilion Materials Management. Updated October 31, 2012. Accessed April 2, 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=f4ca7537-ed49-4dee-9003-48dc001a9dc1
JANUVIA- sitagliptin tablet, film coated. Prescribing Information. Merck Sharp & Dohme LLC. Updated November 14, 2024. Accessed April 2, 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=f85a48d0-0407-4c50-b0fa-7673a160bf01
NESINA- alogliptin tablet, film coated. Prescribing Information. Takeda Pharmaceuticals America, Inc. Updated February 28, 2025. Accessed April 2, 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=a3768c7e-aa4c-44d3-bc53-43bb7346c0b0
ONGLYZA- saxagliptin tablet, film coated. Prescribing Information. Physicians Total Care, Inc. Updated January 9, 2012. Accessed April 2, 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=d45fc842-2563-4421-86af-a55b3191e19b
TRADJENTA- linagliptin tablet, film coated. Prescribing Information. Boehringer Ingelheim Pharmaceuticals, Inc. Updated March 21, 2025. Accessed April 2, 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=c797ea5c-cab7-494b-9044-27eba0cfe40f
BRENZAVVY- bexagliflozin tablet. Prescribing Information. TheracosBio, LLC. Updated November 11, 2025. Accessed April 2, 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=3cdf28fc-4194-4ad6-aa03-c9eaa68da83e
INVOKANA- canagliflozin tablet, film coated. Prescribing Information. Janssen Pharmaceuticals, Inc. Updated March 20, 2025. Accessed April 2, 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=b9057d3b-b104-4f09-8a61-c61ef9d4a3f3
FARXIGA- dapagliflozin tablet, film coated. Prescribing Information. AstraZeneca Pharmaceuticals LP. Updated December 22, 2025. Accessed April 2, 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=72ad22ae-efe6-4cd6-a302-98aaee423d69
JARDIANCE- empagliflozin tablet, film coated. Prescribing Information. Boehringer Ingelheim Pharmaceuticals, Inc. Updated January 30, 2026. Accessed April 2, 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=faf3dd6a-9cd0-39c2-0d2e-232cb3f67565
STEGLATRO- ertugliflozin tablet, film coated. Prescribing Information. Merck Sharp & Dohme LLC. Updated December 20, 2024. Accessed April 2, 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=e6f3e718-bb99-48f1-ab94-b9f0af05fed6
OZEMPIC- oral semaglutide tablet RYBELSUS- oral semaglutide tablet. Prescribing Information. Novo Nordisk. Updated January 30, 2026. Accessed April 1, 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=27f15fac-7d98-4114-a2ec-92494a91da98
Matthews DR, Paldánius PM, Proot P, et al. Glycaemic durability of an early combination therapy with vildagliptin and metformin versus sequential metformin monotherapy in newly diagnosed type 2 diabetes (VERIFY): a 5-year, multicentre, randomised, double-blind trial. Lancet. 2019;394(10208):1519-1529. doi:10.1016/S0140-6736(19)32131-2
Pop-Busui R, Rasmussen S, Deanfield JE, et. al. Oral Semaglutide and Heart Failure Outcomes in Persons With Type 2 Diabetes: A Secondary Analysis of the SOUL Randomized Clinical Trial. JAMA Intern Med. 2026 Feb 2:e257774. doi: 10.1001/jamainternmed.2025.7774
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The information provided in this course is general in nature, and it is designed solely to provide participants with continuing education credit(s). This course and materials are not meant to substitute for the independent, professional judgment of any participant regarding that participant’s professional practice, including but not limited to patient assessment, diagnosis, treatment, and/or health management. Medical and pharmacy practices, rules, and laws vary from state to state, and this course does not cover the laws of each state; therefore, participants must consult the laws of their state as they relate to their professional practice.
Healthcare professionals must consult their employer, healthcare facility, hospital, or other organization for guidelines, protocols, and procedures to follow. The information provided in this course does not replace those guidelines, protocols, and procedures, but is for academic purposes only, and this course’s limited purpose is for the completion of continuing education credits.
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