Getting a type 2 diabetes diagnosis can feel overwhelming. There’s a lot to learn: blood sugar, food, exercise, and medications. One of the biggest questions many people ask early on is, “What medications will I need?” With so many options available today, it helps to understand how doctors choose the right medication to start with. This article breaks down the most common first-line diabetes medications, why they’re used, and how your personal health plays a big role in finding the best fit.

What Does ‘First-Line’ Treatment Mean?

When doctors say “first-line treatment,” they mean the medication that is usually tried first when treating a health problem. For type 2 diabetes, the goal is to lower your blood sugar (also called blood glucose) to a healthy level. Doctors follow research-backed guidelines to know which drugs work best for most people when starting treatment.

That doesn’t mean it’s the only option — but it’s the one that is usually safe, helpful, and cost-effective for many people. It’s kind of like choosing the best place to begin a journey. You want a path that has worked well for others and gives you a strong start.

Is Metformin Still First-Line for Diabetes?

Yes, metformin is still commonly used as a first-line treatment for type 2 diabetes by most experts and medical organizations, including the American Diabetes Association (ADA). Metformin is often the first medication doctors recommend after diet and exercise changes.

Why Metformin Is Usually the First Choice

Metformin has been around for a long time. It’s safe, affordable, and effective. It works by lowering how much sugar your liver produces and helping your body use insulin better. It doesn’t usually cause weight gain, and it rarely causes low blood sugar.

It usually comes in the form of a pill that you take once or twice a day. Some people experience mild side effects like an upset stomach or diarrhea, but these often go away after a few weeks, or if you take the pill with food. If you do experience an upset stomach or diarrhea, ask your doctor about extended-release metformin, which is easier for many people to tolerate.

What if Metformin Isn’t the Best Option?

Doctors often look at other medications too, especially if someone has health conditions like heart or kidney disease, or if metformin isn’t tolerated well.

SGLT2 Inhibitors

Drugs called SGLT2 inhibitors help the body get rid of extra sugar through urine. They are especially helpful for people who also have heart failure or early kidney problems, and they can even protect your kidneys against diabetic nephropathy (damage caused by diabetes). These medications also often lead to some weight loss, which can be helpful for many people with type 2 diabetes. However, they can increase the chance of urinary tract infections, and they are more expensive.

GLP-1 Receptor Agonists

Another group of drugs doctors might choose is GLP-1 receptor agonists. These help the body make the right amount of insulin after meals and also help you feel full, which can support weight loss. GLP-1 medications can also be a great choice if weight or heart health is a concern, but they are usually given as injections (though a pill version also exists) and may cause nausea at first. Like SGLT2 inhibitors, they also tend to be expensive.

Sulfonylureas

There are also older medications, like sulfonylureas, which have been used for many years. These help the pancreas make more insulin and are generally affordable. They usually work quickly and effectively, but they do come with a higher risk of causing low blood sugar and may cause weight gain. For these reasons, doctors may be more cautious about using them, especially when safer alternatives are available. That said, sulfonylureas are a good short-term option to quickly treat uncontrolled type 2 diabetes, especially right after diagnosis.

Thiazolidinediones

Another option, though less commonly used as a first-line treatment today, is thiazolidinediones (like pioglitazone). These help your body use insulin better but can lead to weight gain and fluid retention. They are less popular due to their association with an increased risk of heart failure, but they might still be used in special cases, especially if other medications are not tolerated.

DPP-4 Inhibitors

This class of medications, which includes drugs like sitagliptin and linagliptin, helps your body make more insulin and less glucagon (a hormone that raises blood sugar) after meals. DPP-4 inhibitors work by increasing the GLP-1 hormone that your body naturally produces. Although DPP-4 inhibitors are much less effective than GLP-1 receptor agonists, they work similarly. They are taken as pills once a day and don’t cause weight gain or low blood sugar. They’re easy to take and are usually well tolerated.

DPP-4 inhibitors are a great option for older adults with type 2 diabetes who find that metformin alone isn’t enough and who cannot use GLP-1 receptor agonists. However, DPP-4 inhibitors don’t offer added benefits for heart or kidney protection, and they may be costly depending on insurance.

How Do Doctors Decide Which Drug to Use?

Choosing a diabetes medication isn’t a one-size-fits-all process. Doctors consider many factors when deciding the best treatment plan:

• Your overall health — Heart or kidney issues might point toward SGLT2 inhibitors or GLP-1 agonists.
• Risk of side effects — Some drugs can cause nausea, low blood sugar, or stomach upset.
• Weight goals — GLP-1 drugs often help with weight loss, while sulfonylureas may cause weight gain.
• Cost and insurance — Metformin is inexpensive, while newer drugs can be costly and may not be covered by insurance.
• Your preferences — Do you prefer pills over injections? Are you open to multiple medications?

Your voice matters in this decision. Be open with your doctor about what’s important to you. Together, you’ll find a plan that fits your needs and lifestyle.

Doctors also think about how likely it is that a person will stick with their medication. Some drugs are taken once a day, while you may need to take others multiple times per day or on a schedule. The easier it is for you to follow your treatment plan, the higher the odds that you’ll keep your blood sugar under control. That’s why convenience can be just as important as cost or side effects.

What if One Drug Isn’t Enough?

Sometimes, one drug isn’t enough to control blood sugar. In many cases, doctors will combine medications to help. For example, someone might start with metformin and later add an SGLT2 inhibitor or a GLP-1 agonist. This combo approach can be more effective and may even reduce the need for insulin later on.

Your doctor might recommend combining medications if:

• Your A1c is still too high after trying one medication.
• You have other conditions like high blood pressure or heart disease.
• You need a different type of support, such as weight loss or kidney protection.

Of course, medications are just one part of the big picture. Eating well, staying active, getting enough sleep, and reducing stress are also powerful tools in managing diabetes. Think of your treatment plan like a puzzle. Each piece helps complete the picture.

What About Insulin?

Insulin is usually not the first choice for people with type 2 diabetes. But in some cases, like when you have very high blood sugar levels or when oral medications aren’t enough, your doctor may recommend insulin. It’s also used more often if you’ve had type 2 diabetes for many years. Although some people are nervous about insulin, it’s an important option. It can be used in the short term or long term, and many people find they feel better once their blood sugar is more stable.

Insulin may be given with pills or on its own, and doses can be adjusted as your needs change. If your doctor brings it up, try to stay open — it doesn’t mean you’ve done anything wrong. It simply means your body may need more help managing blood sugar.

Your Path to Diabetes Management

Choosing the right diabetes medication is about finding what works best for your body and your life. Metformin is still the first-line treatment for type 2 diabetes for many people, but other options may be better for you based on your needs.

Always work closely with your healthcare provider. They will help you choose the safest and most effective medication to manage your diabetes and protect your overall health. Here’s what you can do:

• Talk with your doctor about your health, concerns, and preferences.
• Ask questions if you’re unsure about medication.
• Let your doctor know if you have side effects or trouble paying for your medicine.
• Stay involved in your diabetes care — every small step helps.

You don’t have to figure everything out at once. With the right plan and the right support, you can take control of your diabetes and feel your best.

Join the Conversation

On DiabetesTeam, people share their experiences with type 2 diabetes, get advice, and find support from others who understand.

Are you having trouble choosing a medication? Let others know in the comments below.