ADA/EASD urge earlier GLP-1, SGLT2 treatment in T2D

Clinical takeaway: For most adults with type 2 diabetes, consider an SGLT2 inhibitor and/or GLP-1-based therapy early, potentially at diagnosis, rather than automatically starting with metformin alone and escalating stepwise. Treatment should target cardiovascular and kidney protection and weight as well as glycemia.

The American Diabetes Association (ADA) and European Association for the Study of Diabetes (EASD) are calling for earlier use of SGLT2 inhibitors and GLP-1-based therapies in their updated consensus on type 2 diabetes management, published in Diabetologia. The guidance broadens the organizations’ 2022 focus on hyperglycemia to holistic management of diabetes and its associated long-term conditions.

For most patients, the groups recommend early introduction of an SGLT2 inhibitor and/or GLP-1-based therapy, potentially from diagnosis, alongside diabetes self-management education and support and interventions targeting healthy behaviors. These therapies can address glucose and weight without increasing hypoglycemia risk while providing direct organ protection.

That represents an important evolution in metformin’s role. Although metformin remains effective, inexpensive and appropriate for many patients, the cardiovascular and kidney benefits of SGLT2 inhibitors and GLP-1 receptor agonists appear independent of metformin use; in patients with established or high cardiovascular risk, heart failure or CKD, these drugs should therefore be used regardless of whether the patient receives metformin.

For established cardiovascular disease, GLP-1-based therapies with proven benefit are recommended to reduce major adverse cardiovascular events and all-cause mortality, while SGLT2 inhibitors with proven benefit can reduce cardiovascular and heart-failure events and improve kidney outcomes. Combining the two classes may be considered in patients at high cardiovascular risk or with established cardiovascular or kidney disease, irrespective of HbA1c.

SGLT2 inhibitors remain foundational therapy for heart failure and CKD. In CKD, the panel also recommends GLP-1-based therapy with proven benefit and, in patients with albuminuria, a nonsteroidal mineralocorticoid receptor antagonist with proven benefit; earlier combination treatment should be considered when cardiovascular disease, CKD and heart failure coexist.

Weight management also moves closer to the center of diabetes care, with weight targets considered as important as glycemic targets. In patients with overweight or obesity, glucose-lowering agents that promote weight loss should be preferred, while those receiving substantial weight-loss interventions such as GLP-1-based therapy should receive guidance on adequate protein intake and resistance exercise to help preserve lean mass.

The authors conclude that “the ability to transform outcomes for people living with type 2 diabetes is within our grasp,” emphasizing consistent and equitable use of interventions already available.

What’s changed

• Earlier SGLT2 inhibitor and/or GLP-1-based therapy is advocated for most patients, potentially beginning at diagnosis.
• Metformin is no longer the necessary gateway to therapies with cardiovascular and kidney benefit.
• Earlier SGLT2–GLP-1 combination therapy should be considered in patients with concomitant cardiovascular disease, CKD and heart failure.
• The framework expands beyond glycemic management to make weight, organ protection, associated long-term conditions and 24-hour health behaviors central treatment targets.

Source: Davies MJ, et al. (2026 Oct 2) Diabetologia. Management of type 2 diabetes, 2026. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)