Professor Chen Haibing from Shanghai Tenth People’s Hospital (Affiliated Tenth People’s Hospital of Tongji University) points out that diabetes is a highly heterogeneous disease driven by multiple factors in its onset and progression. Meanwhile, patients with diabetes often present with various comorbidities and complications, requiring comprehensive consideration in management. Pharmacotherapy should be administered when necessary on the basis of lifestyle intervention, with optimized glycemic management remaining at the core. In particular, early intensive glycemic control can significantly reduce the risk of future complications and endpoint events. Therefore, the principles of comprehensive management and optimized glycemic control should be upheld throughout the treatment.
Notably, medication safety cannot be overlooked during optimized glycemic control. For patients with multiple comorbidities, especially those with a long disease course, glycemic targets should not be overly strict to avoid an increased risk of hypoglycemia. In contrast, relatively stricter targets [e.g., HbA1c <6.5% or even normal] can be adopted for younger patients with a short disease duration, long life expectancy and no obvious complications. Accordingly, regimens with excellent hypoglycemic efficacy, low hypoglycemia risk and good tolerability should be prioritized in drug selection to better meet the glycemic control needs of different patients.
Hypoglycemic agents should be prescribed individually based on the unique pathophysiological characteristics of each patient, as each class has its applicable population. Taking DPP-4 inhibitors as an example, they exert definite hypoglycemic effects, reducing HbA1c by 0.4%–0.9%[1]. Moreover, they have outstanding safety advantages: they do not increase the risk of hypoglycemia when used alone and have a neutral impact on body weight. Elderly patients with diabetes often suffer from multiple comorbidities and complications, so medication safety is highly valued. Given the low hypoglycemia risk and favorable overall safety profile, DPP-4 inhibitors are recommended as first-line agents in the Chinese Guidelines for the Diagnosis and Management of Diabetes in the Elderly (2024 Edition)[2], highlighting their prominent advantages in elderly patients.
It should be noted that the application of DPP-4 inhibitors is not limited to elderly patients; they also have unique value in young patients with early-onset type 2 diabetes (onset before 40 years old). Such patients usually have a short disease course and fewer comorbidities and complications, with greater emphasis on intensive glycemic control, weight management and delaying disease progression. DPP-4 inhibitors not only provide excellent and safe glycemic control with neutral weight effects, but also improve β-cell function, thereby effectively delaying disease progression and better meeting the long-term management needs of young patients.
In addition, DPP-4 inhibitors have been upgraded to essential hypoglycemic agents for primary medical institutions in the newly released National Guidelines for the Prevention and Management of Diabetes in Primary Care (2025). This recommendation is mainly based on their reliable hypoglycemic efficacy, excellent safety and convenient administration, which facilitate diabetes management at the primary level. In conclusion, the elevated status of DPP-4 inhibitors in multiple guidelines reflects the current clinical consensus on glycemic management: emphasizing both efficacy and safety, with consideration for weight control and long-term benefits. Their wide applicability in elderly patients, young early-onset patients and primary care populations provides important support for optimizing medication strategies and achieving long-term stable glycemic control in medical institutions at all levels.