MILAN — A new updated joint consensus statement on type 2 diabetes (T2D) management emphasizes earlier intervention with glucose-lowering medications and a broader focus beyond hyperglycemia to include assessing and treating complications as part of overall diabetes management.

“This update has broadened the focus from the management of hyperglycemia to the holistic management of type 2 diabetes and its risk of associated long-term conditions. Earlier use, potentially from diagnosis, of SGLT2 inhibitors or/and GLP-1-based therapies to offer organ protection and improve long-term outcomes in type 2 diabetes is advocated,” said writing committee co-chair Melanie J. Davies, MB ChB, MD, professor of diabetes medicine at the University of Leicester in Leicester, England.

In addition, earlier combination use of SGLT2 inhibitors and GLP-1-based therapies is advised for people with concomitant cardiovascular disease (CVD), chronic kidney disease (CKD), and heart failure, she added.

“The ability to transform outcomes for people living with type 2 diabetes is within our grasp through consistent, equitable, and systemic implementation of strategies and therapies already available,” said Davies, who is also an honorary consultant diabetologist at University Hospitals of Leicester NHS Trust.

The new statement was presented here at the European Association for the Study of Diabetes (EASD) 2026 Annual Meeting and simultaneously published in the two organizations’ respective journals, Diabetes Care and Diabetologia. It updates the previous American Diabetes Association/EASD T2D management guidance, published in 2022.

Nutrition, Physical Activity, and Self-Management

The new consensus recommendations are presented in both text and graphics and include a holistic, multifactorial approach to T2D. A summary of medical nutrition therapy outlines different dietary patterns and their respective metabolic effects, suggesting a preference for the Mediterranean diet for those with established CVD.

Physical activity advice is based on the “5 S’s”: standing to minimize excessive sitting; stepping 8000-10,000 steps per day; sweating through at least 150 minutes weekly of moderate to vigorous activity; strengthening exercises 2-3 days weekly; and sleeping 7-8 hours nightly.

The document also advises referral to diabetes self-management education and support, both for enhancing self-efficacy and for addressing social determinants of care. It also recommends delivery of person-centered care via a care team and technology. 

Updated With Added Evidence-Based Guidance

With the overarching treatment goal of preventing longitudinal complications associated with T2D, the new consensus advises initiation of an SGLT2 inhibitor or/and a GLP-1 “early to modify disease and complication risk.”

Recommendations from 2022 are maintained for use of these medications as first-line based on their indications for reducing cardio-renal risk, ie, either drug class for people with established CVD, and SGLT2 inhibitors or semaglutide for people with CKD. 

Specific therapeutic recommendations based on new data include:

• For individuals with atherosclerotic cardiovascular disease and heart failure, combination therapy withSGLT2 inhibitor and GLP-1-based therapy could be considered for those at high risk for CVD or with established CVD or CKD, regardless of A1c levels.
• In people with peripheral arterial disease, semaglutide can be used to improve symptoms.
• In addition to the previous recommendation for SGLT2 inhibitors in people with heart failure, now semaglutide or tirzepatide are recommended for people with obesity and heart failure with preserved ejection fraction (HFpEF).
• A nonsteroidal mineralocorticoid receptor antagonist (MRA) with proven benefit is now recommended for people with HFpEF/heart failure with mildly reduced ejection fraction and for those with albuminuria when estimated glomerular filtration rate is > 25 mL/min/1.73 m².
• For those at high risk for atrial arrhythmias, semaglutide or an SGLT2 inhibitor is recommended.
• In people with CKD, a GLP-1-based therapy with proven benefit is recommended with semaglutide specifically to reduce the risk for CKD progression, while a nonsteroidal MRA is recommended for those with a urinary albumin creatinine ratio > 3.0 mg/g.
• SGLT2 inhibitors should form the foundation for heart failure/CKD protection, while GLP-1-based therapies could be added for incremental major adverse cardiac events and kidney benefit plus weight/metabolic control. Finerenone could be added, particularly in albuminuric CKD, to further reduce cardio-kidney events.
• Early combination therapy should be considered in people with concomitant CVD, CKD, and heart failure.

A completely new section has been added addressing metabolic dysfunction-associated steatotic liver disease (MASLD) and metabolic dysfunction-associated steatohepatitis (MASH). It includes guidance for weight reduction and lifestyle modification for those with MASLD, use of a GLP-1-based therapy with proven benefit for those with obesity and MASLD, and a GLP-1 or pioglitazone for those with MASH. Combination treatment can also be considered.

Other new recommendations include prioritizing a GLP-1 agonist with proven benefit for people with T2D who have obesity and sleep apnea and early use of SGLT2 inhibitors and GLP-1-based therapies alone or in combination for early-onset T2D, albeit with caution against use during pregnancy.

Good Document Overall, But Cost Is an Issue

Asked to comment on the new document, independent consultant Charles Alexander, MD, told Medscape Medical News, “I think it’s very good. I really don’t have much at all to criticize.”

However, Alexander noted that regarding first-line SGLT2 inhibitors or GLP-1-based therapies, “depending on the country, that may get into issues of access and affordability. Metformin and sulfonylureas are clearly the cheapest, and SGLT2 inhibitors and GLP-1s in most countries are quite a bit more expensive.”

As for the US, “we’ve got to deal with the money issue and the access issue. In the US, whether you’re on a particular medicine depends as much on how much money you have as what you need. People who have high-deductible insurance don’t want to ever see a doctor because they’re paying so much out of pocket.”

Don’t Give Up on Metformin Just Yet

The particular issue of SGLT2 inhibitor use in people with recent-onset T2D who are without complications at baseline was addressed in a study that was also presented at EASD, so the data weren’t available for the guidance evidence review. Called the SMARTEST trial, it showed that use of the SGLT2 inhibitor dapagliflozin in those individuals did not improve macrovascular, microvascular, or mortality outcomes compared with metformin. 

The lead author of the SMARTEST trial, Jan W. Eriksson, MD, PhD, professor in the Department of Medical Sciences, Uppsala University, and diabetologist at Uppsala University Hospital in Uppsala, Sweden, told Medscape Medical News, “SGLT inhibitor benefits have been shown in people who already have heart disease or kidney disease and in those with a very high load of cardiovascular risk factors. [The consensus authors] didn’t present evidence for uncomplicated type 2 diabetes. I think that was actually a gap in the recommendation.”

Martin Lundqvist, PhD, a postdoctoral student at Uppsala University and co-author of the SMARTEST trial, added, “Metformin is not a bad drug according to our findings. At least it’s not inferior to dapagliflozin, and dapagliflozin is not superior to metformin. There has been a gradual down-prioritizing of the use in metformin, and perhaps that’s not really called for according to our findings. I think more studies are needed to actually challenge the use of metformin for first-line treatment.”

Davies reported serving as a consultant/advisor and speaker for Eli Lilly, Novo Nordisk, and Sanofi; as a consultant/advisor for Kailera; attending advisory boards for AbbVie, Amgen, AstraZeneca, Biomea Fusion, Carmot/Roche, Daewoong Pharmaceutical, Sanofi, Zealand Pharma, Regeneron Pharmaceuticals, GSK, Innovent Bio, and EktaH; and as a speaker for AstraZeneca, Boehringer Ingelheim, Obesity Alliance, and Zuellig Pharma. She also reported receiving grants from AstraZeneca, Boehringer Ingelheim, and Novo Nordisk.

Alexander reported being an advisor to Diatribe. Eriksson reported receiving honoraria and research support from AstraZeneca and honoraria from Novo Nordisk, Merck Sharp & Dohme, and Ilya Pharma. Lundqvist reported having no disclosures.

Miriam E. Tucker is a freelance journalist based in the Washington, DC area. She is a regular contributor to Medscape, with other work appearing in the Washington Post, NPR’s Shots blog, and Diatribe. She is on X @MiriamETucker and BlueSky @miriametucker.bsky.social.