Disease-modifying anti-diabetic drugs (DMADDs): bridging the SIMPLE approach to disease interception
Abstract
The traditional glucose-centric paradigm of type 2 diabetes management is being superseded by growing evidence that certain agents, sodium-glucose cotransporter-2 inhibitors (SGLT2i), glucagon-like peptide-1 receptor agonists (GLP-1RA), and pioglitazone, confer cardiovascular, renal, and hepatic benefits that extend well beyond glycemic control. Building on the previously proposed "diabetes/disease-modifying drugs (DMDs)" concept introduced through the SIMPLE framework, we propose a more mechanistically precise term: Disease-Modifying Anti-Diabetic Drugs (DMADDs). DMADDs are defined by four criteria: glucose-independent clinical benefit, durable organ-specific protection, mechanistic evidence of anti-inflammatory or anti-fibrotic activity, and sustained legacy effects or remission potential. Using these criteria, SGLT2i, GLP-1RA, and pioglitazone emerge as prototypical agents, while metformin, dipeptidyl peptidase-4 (DPP-4) inhibitors, insulin, and sulfonylureas do not meet the full threshold. We explicitly explain why metformin and DPP-4 inhibitors are excluded as DMADDs, situate the DMADD framework within the heterogeneity of type 2 diabetes and against what non-pharmacological interventions can achieve, and state the limitations of the proposal. Recent evidence reinforces this framework: the SOUL trial established cardiovascular superiority for oral semaglutide, extending disease-modifying properties beyond injectable formulations, while Phase 3 TRIUMPH data position…
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