ACP Says Cost a Consideration When Adding Therapy for Type 2 Diabetes

The American College of Physicians' oral medication guideline for treating type 2 diabetes is the first update since 2012, and it reflects many new medications that have received FDA approval since that time.

The American College of Physicians (ACP) on Tuesday updated its oral medication guidelines for treating type 2 diabetes (T2D), with a specific tip for patients: ask what you will pay for your medication.

ACP published its new guideline, last updated in 2012, in the Annals of Internal Medicine. The journal published a separate summary for patients that features questions to ask physicians, including: “How much will the oral medicines cost?”

The guideline calls for starting with metformin, and if a second oral medication is needed, to select from among sodium glucose co-transporter-2 inhibitors (SGLT2s), dipeptidyl peptidase-4 (DPP-4) inhibitors, sulfonylureas, or thiazolidinediones.

The update reflects the many new medications that have received FDA approval since 2012, with SGLT2s and combinations chief among them, as well as multiple studies evaluating the safety and effectiveness of available therapies.

“Metformin, unless contraindicated, is an effective treatment strategy because it has better effectiveness, is associated with fewer adverse effects, and is cheaper than most other oral medications,” Nitin S. Damle, MD, MS, MACP, the group’s president, said in a statement. Metformin is included in several combination therapies that have received FDA approval, which allow patients to take the dual therapy in a single, daily pill.

Besides the benefits for lowering glycated hemoglobin and slowing disease progression, Damle said metformin is associated with weight loss, an added benefit given rising rates of obesity and the drug’s relatively low cost.

He addressed the issue of cost directly: “Adding a second medication to metformin may provide additional benefits,” Damle said. “However, the increased cost may not always support the added benefit, particularly for the more expensive, newer medications. ACP recommends that clinicians and patients discuss the benefits, adverse effects, and costs of additional medications.”

ACP’s guideline is important because its recommendations are likely to reach primary care physicians, who diagnose and treat the majority of patients with T2D. On its website, ACP said its members include 148,000 specialists and subspecialists in internal medicine.

The group’s call for physicians to discuss cost with patients comes as studies and reports from those in the field show patients with diabetes may not fill prescriptions for high-cost medications, or they may start and then discontinue them if the out-of-pocket costs are too high.

Diabetes affects 29 million people in the United States, with most being diagnosed with T2D. An estimated 86 million people have prediabetes. Diabetes is the seventh leading cause of death in the United States, according to CDC.


Qaseem A, Barry MJ, Humphrey LL, Forciea MA, for the Clinical Guidelines Committee of the American College of Physicians. Oral pharmacologic treatment of type 2 diabetes mellitus: a clinical practice guideline update from the American College of Physicians [published online January 3, 2017]. Ann Intern Med. doi: 10.7326/M16-1860.

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