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Diabetes Medications

Article Last Updated: 2 January 2026

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Pharmacology and Prescription Information

Drug class	MoA	Examples	Overall clinical profile	Important side effects	Caution and contraindications
Biguanides	Metformin	Enhances the effect of insulin by: ↑ Peripheral insulin sensitivity (increases glucose uptake into cells) ↓ Hepatic gluconeogenesis	Promotes weight loss No risk of hypoglycaemia	GI upset – most common Metallic taste in the mouth Vitamin B12 deficiency Lactic acidosis (rare but serious)	Avoid if eGFR <30 Acute metabolic acidosis (including lactic acidosis and DKA) Stop in states of hypoxia (due to risk of lactacidosis) Shock Sepsis Respiratory failure
SGLT-2 inhibitor	Dapagliflozin, empagliflozin	Inhibit SLGT-2 in proximal renal tubule → ↓ glucose reabsorption	Promotes weight loss Cardioprotective effect	DKA (euglycaemic DKA possible) Risk of hypoglycaemia From the effects of glycosuria UTIs and genital infections Dehydration Fournier’s gangrene (necrotising fasciitis of the genitalia / perineum) It is normal to see glycosuria (typically ++ / +++ on urine dipstick) in those who take SGLT-2 inhibitors	T1DM Previous DKA (use with caution) Recurrent UTI (use with caution) Avoid if eGFR <15 Reduced efficacy if eGFR <45
Thiazolidinediones (TZD)	Pioglitazone	Activation of PPARγ in adipocytes → ↑ insulin sensitivity (increases glucose uptake into cells)	No warnings in renal impairment	ELBOW: E: oedema (↑ risk of heart failure) L: liver toxicity B: bladder cancer O: osteoporosis W: weight gain	Heart failure Previous / active bladder cancer Uninvestigated macroscopic haematuria
Sulfonylurea	Glicazide, glimepiride	↑ Insulin secretion	Useful to rapidly lower blood glucose	Risk of hypoglycaemia Weight gain	Presence of ketoacidosis G6PD deficiency (use with caution)
DPP-4 inhibitor	Sitagliptin, linagliptin	Inhibits DPP-4 (enzyme that breaks down GLP-1) → ↑ GLP-1 activity	Weight neutral Good tolerability No risk of hypoglycaemia Can be used in renal impairment	Headache – common Acute pancreatitis Constipation	History of pancreatitis (use with caution) Dose reduction if eGFR <45 (apart from linagliptin)
GLP-1 agonist	Liraglutide, exenatide, semaglutide	3 main effects of GLP-1: Delayed gastric emptying ↑ Insulin secretion ↓ Glucagon secretion	Has multiple additional benefits: Weight loss Cardioprotective Renoprotective Note that it is given via an injection	Effect of delayed gastric emptying Gastroparesis-like symptoms Risk of pulmonary aspiration during GA / deep sedation DKA (when used in combination with insulin, esp. after insulin discontinuation or rapid dose reduction) Acute pancreatitis Gall bladder disorder Risk of medullary thyroid carcinoma	Diabetic gastroparesis Chronic pancreatitis Personal / family history of medullary thyroid carcinoma or MEN2 syndrome

Acarbose is another anti-diabetic drug, but rarely used:

It has a poorer anti-hyperglycaemic effect than many other antidiabetic drugs
MoA: Reduce GI glucose absorption
AEs: bloating, flatulence, diarrhoea

High-Yield Facts

Metformin Dosing

Drugs at Risk of Hypoglycaemia

Drugs at Risk of Weight Gain

Drugs in Renal Impairment

Drug	Use in renal impairment
Metformin	Avoid if eGFR <30
SGLT-2 inhibitor	Avoid if eGFR <15 NB reduced efficacy if eGFR <45
Sulfonylurea	Dose reduction in renal impairment Avoid in severe renal impairment (due to risk of hypoglycaemia)
DPP-4 inhibitor (apart from linagliptin)	Dose reduction if eGFR <45
GLP-1 agonist	Avoid in renal impairment (exact cut-offs depend on the drug)

Drugs to avoid in T1DM

Drugs and Pregnancy

Drugs to Avoid in Pancreatitis

References

NICE BNF
NICE guideline Type 2 diabetes in adults: management
Drug Therapies for Diabetes Int J Mol Sci. 2023 Dec 5;24(24):17147

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