The 2026 ADA/EASD consensus: Why early SGLT2/GLP-1 works

The consensus has been published since 2006 and was last updated in 2022. A 16-member writing group with equal representation from both organisations, co-chaired by Professor Melanie Davies for EASD and Professor John Buse for ADA, searched PubMed for randomised trials, systematic reviews and meta-analyses published between 1 May 2022 and 31 December 2025. Evidence was appraised with GRADE-informed methods, the draft went to public comment at the ADA meeting in New Orleans in 2026, and the report then underwent external peer review before approval by both societies.¹

The authors say this update broadens the focus from managing hyperglycaemia to the holistic management of type 2 diabetes and its associated multiple long-term conditions, from heart, kidney and liver disease to sleep apnoea and mental health. Fundamental care includes healthy eating, 24-hour physical behaviours, psychological support and weight management, delivered with diabetes self-management education and support. The report says these behaviours are "foundational, not adjunctive."¹

What Changes in Prescribing

The biggest shift is in sequencing. The report states that SGLT2 inhibitors and GLP-1-based therapy, which here includes tirzepatide, confer cardiovascular benefits independent of metformin and should be first-line therapeutic considerations. Most people with type 2 diabetes would benefit from early introduction of an SGLT2 inhibitor, a GLP-1-based therapy or both, potentially from diagnosis, alongside education and health behaviour interventions. The authors argue this targets glucose without hypoglycaemia risk, weight and organ protection together, and helps avoid clinical inertia.¹

For people with established cardiovascular disease, the report recommends a GLP-1-based therapy with proven benefit to reduce major adverse cardiovascular events and all-cause mortality, or an SGLT2 inhibitor with proven benefit. Because benefits may be additive, combination therapy could be considered in people at high risk or with established cardiovascular or kidney disease irrespective of HbA1c, and early combination should be considered in people with concurrent cardiovascular, kidney and heart failure disease. We have covered the evidence for combining the two classes before.¹

In chronic kidney disease, an SGLT2 inhibitor with proven benefit should be started regardless of albuminuria and continued until kidney replacement therapy, a GLP-1-based therapy should be added, with semaglutide indicated to slow CKD progression, and a non-steroidal mineralocorticoid receptor antagonist should be used when urine albumin-to-creatinine ratio exceeds 3.0 mg/mmol. For people with obesity, type 2 diabetes and MASLD, a GLP-1-based therapy is recommended, and tirzepatide or a GLP-1 receptor agonist could be prioritised in obstructive sleep apnoea.¹

Weight is now a formal target. Weight targets "achieved by any means" are described as being as essential as glycaemic targets, agents with weight-lowering effects should be preferred in people with overweight or obesity, and metabolic surgery could be considered at a BMI of 30 or above and should be considered at 35 or above (27.5 and 32.5 for people of Asian ancestry). Intensive lifestyle therapy aiming for 10% or greater weight loss is suggested with the possibility of remission. If insulin is needed, it should start as basal insulin only, usually after GLP-1-based therapy, while keeping SGLT2 inhibitors, and sulfonylureas should be stopped.¹

Targets, Access and Caveats

Targets are largely unchanged. A reasonable HbA1c for most adults with enough life expectancy to see microvascular benefit is around 48 to 53 mmol/mol (6.5% to 7%) or lower, with 48 mmol/mol or lower for people managed with lifestyle alone or drugs that do not cause hypoglycaemia, and for early-onset disease diagnosed before age 40. Continuous glucose monitoring targets a time in range above 70%. Blood pressure should be below 130/80 mm Hg, with a systolic goal under 120 mm Hg encouraged in high-risk people, and statins are recommended for most people over 40.¹

Behaviour gets specific numbers. The "five S's" are standing, stepping, sweating, strengthening and sleep, with a minimum of 150 minutes a week of moderate-to-vigorous aerobic activity and resistance exercise 2 to 3 times a week. The report cites body composition analyses, including SURMOUNT-1, suggesting about 25% to 40% of weight lost with GLP-1-based therapies reflects lean mass loss, while noting other studies report figures nearer 15%. It advises protein guidance and resistance exercise for anyone losing substantial weight, and caution about potent agents in frail people.¹

Cost and access are acknowledged as limits. The authors point to the classes now being on the WHO essential medicines list and to prices easing as patents expire, but they say that where resources are short the highest-risk groups should be prioritised, using absolute rather than relative risk reductions. In lower-risk people, such as those with minimal hyperglycaemia, limited excess weight and no organ damage, a more stepwise approach may be appropriate. Certainty is also lower in people with cardiovascular risk factors but no established disease, because some outcome trials enrolled only established disease.¹

Other caveats follow. The recommendations reflect the values and preferences of the writing group, and the authors acknowledge limitations in the evidence base, including thin data in younger and older people, women and different racial and ethnic groups, though they say that is not a reason to withhold treatment. They call current remission definitions based on glycaemic thresholds "inherently simplistic" and suggest the broader concept of type 2 diabetes modification. The activity was funded by ADA and EASD, and the authors report extensive relationships with pharmaceutical companies in the disclosures at the end of the paper.¹