Dr. Li opened the latest guideline as a patient, diagnosed with type 2 diabetes for five years, was waiting for an adjustment to his medication regimen—the original treatment plan was no longer able to keep his glycated hemoglobin within the target range.

"Mr. Wang, based on the latest treatment guidelines, we may need to adjust your glucose-lowering regimen." In the consultation room, Dr. Li was explaining the adjustment of the treatment plan to a patient who had been suffering from type 2 diabetes for five years.

This patient's glycated hemoglobin had recently been hovering around 7.8%, accompanied by mild hypertension and an overweight condition. Faced with the bewildering array of glucose-lowering medications, he often felt confused: "With so many drugs, which one is really the best for me?"

The release of the 2025 edition of the "Chinese Guidelines for the Prevention and Treatment of Type 2 Diabetes" offers clearer and more personalized pathways for glucose-lowering drug treatment to clinicians and patients with diabetes. Building upon the continuation of the "patient-centered" philosophy, the new edition incorporates the latest clinical research evidence and introduces significant adjustments to the selection and application of glucose-lowering medications.

01 Treatment Pathways Are Clearer, These Medications Become the "New Favorites"

One of the most notable highlights of the new guidelines is the updated flowchart for the pharmacological treatment of type 2 diabetes. Compared to previous editions, the 2025 guidelines place greater emphasis on the strategy of selecting drugs based on the patient's complications and comorbidities.

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The new guidelines explicitly state that for patients with type 2 diabetes who also have atherosclerotic cardiovascular disease or high-risk factors, heart failure, or chronic kidney disease, regardless of their glycated hemoglobin levels, medications with proven cardio-renal protective effects should be used in combination with metformin.

These medications primarily include two classes: GLP-1 receptor agonists and SGLT2 inhibitors. The status of these two drug classes has been elevated from "alternative options" in the past to "essential choices" for specific populations, marking a shift in China's philosophy of diabetes management from a singular focus on "glucose lowering" to "comprehensive risk management."

The guidelines also specifically emphasize the principle of individualized treatment, recommending that doctors comprehensively consider factors such as the patient's age, disease duration, hypoglycemia risk, body weight, liver and kidney function, financial status, and personal preferences when selecting medications.

The new pathway map divides treatment options into three levels: monotherapy, dual therapy, and multiple combination therapy, with clear drug selection and adjustment recommendations at each step, making clinical decision-making more evidence-based.

02 Four Core Changes Redefining the Choice of Glucose-Lowering Medications

Change 1: Elevated Status of GLP-1 Receptor Agonists

The new edition guidelines elevate GLP-1 receptor agonists from a second-line therapy to one of the first-line options for specific patient populations. This class of drugs not only effectively lowers blood glucose but also provides multiple metabolic benefits such as weight loss, blood pressure reduction, and improved lipid profiles.

For type 2 diabetes patients with obesity, especially those with a body mass index ≥27 kg/m², GLP-1 receptor agonists are prioritized as the recommended treatment. This change reflects an increased emphasis on weight management for diabetes patients.

Change Two: Expanded Indications for SGLT2 Inhibitors

The indications for SGLT2 inhibitors have been further expanded; they are not only used for glycemic control but are also explicitly recommended for type 2 diabetes patients with comorbid cardiovascular disease, heart failure, or chronic kidney disease, regardless of their glycemic control status.

The unique feature of these drugs lies in their insulin-independent mechanism for lowering blood glucose, which works by promoting urinary glucose excretion to reduce blood sugar levels. Additionally, they offer extra benefits such as weight loss, blood pressure reduction, and lowered uric acid levels.

Change Three: New Uses for Old Drugs, Precise Targeting

For classic hypoglycemic drugs such as sulfonylureas and glinides, which act as insulin secretagogues, the new guidelines have provided more precise positioning. These medications remain effective but are more suitable for patients without cardiovascular disease, low hypoglycemia risk, and limited financial resources.

It is noteworthy that the guidelines specifically remind patients who are on long-term sulfonylurea therapy to regularly assess pancreatic β-cell function, in order to avoid functional exhaustion due to overstimulation.

Change Four: Early Combination Therapy is Recommended

"Treatment inertia" is a common issue in diabetes management. The new guidelines encourage initiating combination therapy as early as possible if glycemic targets are not met after three months of monotherapy, rather than simply increasing the dose of a single medication or prolonging the observation period.

This "early intensification" strategy helps achieve glycemic control goals more quickly and may produce long-term metabolic memory effects, delaying the onset and progression of complications.

03 Analysis of Medication Examples: Which Drugs Made the List?

The specific drug classes and representative drugs mentioned in the 2025 guidelines include:

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GLP-1 Receptor Agonist Class:

This class of drugs mimics the action of the gut hormone GLP-1, promoting insulin secretion, inhibiting glucagon release, delaying gastric emptying, and increasing satiety. Representative drugs include liraglutide, semaglutide, and dulaglutide.

Particularly for semaglutide, multiple studies in recent years have confirmed its significant cardiovascular protective effects, reducing the risk of major adverse cardiovascular events, making it the preferred drug for type 2 diabetic patients with cardiovascular disease.

SGLT2 Inhibitor Class:

This class of drugs lowers blood glucose by inhibiting glucose reabsorption in the proximal renal tubules, thereby increasing urinary glucose excretion. Representative drugs include empagliflozin, dapagliflozin, and canagliflozin.

Among these, empagliflozin has been proven to reduce the risk of cardiovascular death, while dapagliflozin shows clear benefits in patients with heart failure, regardless of whether they have diabetes.

New Insulin Formulations:

The updated guidelines also include newer insulin analogs, such as ultra-long-acting insulins like degludec and glargine U300, as well as rapid-acting insulin analogs.

These new insulin formulations provide more stable blood glucose control and reduce the risk of hypoglycemia, particularly for patients with type 2 diabetes who require insulin therapy.

New Positioning of Classic Drugs:

Metformin remains the first-line drug of choice for type 2 diabetes treatment, unless contraindicated or not tolerated.

DPP-4 inhibitors such as sitagliptin and saxagliptin are suitable for elderly patients or those at high risk of hypoglycemia, as they do not increase the risk of hypoglycemia and have a neutral effect on body weight.

04 New Strategies in Pharmacotherapy: Personalized Selection is Key

The core concept of the 2025 edition guidelines can be summarized as "one center, two foundational points": patient-centered, with blood glucose control and complication prevention as the foundational points.

Patients with comorbid cardiovascular disease or high-risk factors: priority should be given to GLP-1 receptor agonists or SGLT2 inhibitors; even if blood glucose targets have been met, their use is still recommended to obtain cardio-renal protective benefits.

Patients with comorbid chronic kidney disease: SGLT2 inhibitors (such as canagliflozin, dapagliflozin) have been proven to delay the progression of kidney disease and reduce proteinuria, making them a priority choice for this patient group.

For diabetic patients with obesity or overweight: GLP-1 receptor agonists are an ideal choice because they not only lower blood glucose but also help reduce weight and improve multiple abnormalities of metabolic syndrome.

For elderly diabetic patients: Drugs with low hypoglycemic risk should be prioritized, such as DPP-4 inhibitors, SGLT2 inhibitors, or some GLP-1 receptor agonists, while avoiding potent insulin secretagogues.

The guidelines also particularly emphasize the combination of drug therapy with lifestyle interventions. Regardless of which drug is chosen, the foundational roles of dietary control, regular exercise, and weight management should not be overlooked.

"The new guidelines are not meant to negate traditional drugs but to help us more precisely select the appropriate drug combinations for each patient," explained Dr. Li. "For example, in Mr. Wang's situation, we might consider adding a GLP-1 receptor agonist on top of metformin, which can control blood glucose, aid in weight loss, and protect cardiovascular health."

Guideline updates are not merely about recommending new drugs or discontinuing old ones; they are based on the latest research evidence to provide the most suitable treatment plans for different types of patients.

For over 100 million Chinese patients with type 2 diabetes, this means more precise and personalized treatment approaches. There is no one-size-fits-all solution for diabetes management; each individual is unique and requires a tailored treatment strategy.

The release of the new guidelines marks a new phase of more refined and personalized diabetes prevention and treatment efforts in China, offering clinicians more scientific decision-making tools and ultimately benefiting the vast number of diabetes patients.

Disclaimer: The above content is for reference only and should not be used as a basis for treatment!