The 2026 ADA/EASD consensus report is a substantive reframing of type 2 diabetes care, rather than a narrow update to glucose-lowering algorithms. Compared with the 2022 report, it explicitly broadens the objective from management of hyperglycemia to lifelong, person-centred management of weight, cardiometabolic risk, organ protection, functional health, and multiple long-term conditions (MLTCs). The ADA describes this as a shift toward individualized goals for weight and heart, kidney, and liver protection alongside glucose management.
Most importantly, the document moves away from an implicitly sequential “add treatment when HbA1c remains above target” model. It supports an individualized package of behavioral and pharmacologic measures that can involve both treatment intensification and deintensification, with early—potentially diagnosis-time—use of an SGLT2 inhibitor and/or GLP-1–based therapy for most people, alongside DSMES and cardiovascular risk-factor management. This is a major change in emphasis, but it is not a universal mandate for every patient to receive both drug classes: the report preserves a more stepwise approach for lower-risk people with minimal hyperglycemia, less excess weight, no organ damage, limited life expectancy, contraindications, poor tolerability, or constrained resources.
A broader definition of “diabetes care”
The update formally pivots from traditional microvascular screening alone to proactive assessment and treatment of coexisting conditions that meaningfully shape outcomes. It gives much greater prominence to heart failure, CKD, MASLD/MASH, obesity, obstructive sleep apnea, atrial arrhythmias, frailty, sarcopenic obesity, mental health, cognitive impairment, sexual and reproductive health, and social determinants of health. The associations specifically highlight the expansion beyond usual eye, foot, and kidney surveillance to conditions such as heart failure, liver disease, OSA, periodontal health, and psychological conditions.
A practical conceptual update is the use of MLTCs—multiple long-term conditions—as an organizing principle. Treatment selection is no longer presented primarily as a response to HbA1c, but as a decision based on the whole clinical profile: adiposity or sarcopenia, cardiorenal risk, liver disease, frailty, side-effect susceptibility, preferences, reproductive potential, access, and social context.
Earlier cardiorenal protection
The report strengthens the position that the cardiovascular and kidney benefits of SGLT2 inhibitors and GLP-1–based therapies are independent of metformin use and of the need for additional glucose lowering. Metformin remains a valuable, inexpensive glucose-lowering drug, but it is no longer treated as a necessary prerequisite before initiating an SGLT2 inhibitor or GLP-1–based therapy when there is a compelling cardiorenal indication.
Key refinements include:
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Established ASCVD: GLP-1–based therapy is preferred for MACE and all-cause mortality reduction; SGLT2 inhibitors are also options, with benefits spanning MACE, heart failure, mortality, and kidney outcomes. Combination therapy may be considered in people with established or high-risk CVD or kidney disease.
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Heart failure: SGLT2 inhibitors are positioned as foundational therapy across the ejection-fraction spectrum. Semaglutide or tirzepatide is recommended to improve symptoms in people with obesity and HFpEF; a nonsteroidal MRA with proven benefit is recommended in HFpEF or mildly reduced EF for heart-failure and mortality benefit.
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CKD: SGLT2 inhibitors should be initiated for kidney and heart-failure protection regardless of albuminuria and continued until kidney replacement therapy is indicated. GLP-1–based therapy is recommended for additional kidney, heart-failure, MACE, and metabolic benefit. Finerenone is recommended in albuminuric CKD, with an eGFR above 25 mL/min/1.73 m².
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Layering therapy: The report newly articulates SGLT2 inhibitors as the foundation for CKD/heart-failure protection, with GLP-1–based therapies and finerenone layered according to the person’s risk profile—especially in concomitant CVD, CKD, and heart failure.
Crucially, the guideline is careful about lower-risk populations: relative risk reductions may be consistent, but absolute benefit is smaller when baseline event rates are low. Treatment choices should therefore reflect baseline absolute cardiorenal risk, time horizon, access, and feasibility—not relative effects alone.
GLP-1 therapies, tirzepatide, and weight
The report adopts the term “GLP-1–based therapies” to include GLP-1 receptor agonists and tirzepatide, the dual GIP/GLP-1 agonist. This change recognizes that these medicines are now used not only for glucose lowering, but also for weight management and organ protection.
Several developments receive considerably greater weight than in 2022:
Tirzepatide is incorporated throughout the care framework, including for weight management, HFpEF symptom improvement in obesity, OSA, and glycemic control. Its dedicated cardiovascular outcomes trial showed noninferiority to dulaglutide, while comparisons with an imputed placebo are described as indirect and exploratory—not definitive placebo-controlled proof.
Semaglutide has expanded relevance in CKD, HFpEF with obesity, PAD symptoms, and biopsy-proven MASH with moderate-to-advanced fibrosis.
Oral and higher-dose options are recognized, including oral semaglutide and orforglipron, but choices remain contingent on national approval, indication, availability, efficacy, safety, and cost.
Weight is elevated to a core treatment target, alongside HbA1c. A loss of 5% is recognized as clinically meaningful, while loss approaching or exceeding 15%—especially early in disease—may increase the likelihood of normoglycemia and remission.
The document also adds an important corrective to simplistic weight-loss messaging: substantial weight loss can include loss of lean mass. It therefore explicitly recommends adequate protein intake and resistance exercise for people receiving GLP-1–based therapies or metabolic surgery, particularly those at risk of sarcopenia or frailty.
Liver, OSA, technology, and lifestyle
MASLD/MASH is no longer peripheral. Weight reduction and physical activity are foundational; GLP-1–based therapy is recommended for people with obesity, type 2 diabetes, and MASLD. In biopsy-proven MASH, a GLP-1–based therapy with proven benefit is preferred, with pioglitazone or tirzepatide as options. Semaglutide is identified as the only glucose- or obesity-directed therapy approved for noncirrhotic MASH with moderate or advanced fibrosis, while resmetirom requires specialist-led consideration in F2–F3 fibrosis. SGLT2 inhibitors should continue for their established metabolic, cardiovascular, and kidney indications, but are not recommended primarily as liver-directed treatment.
The report also introduces the five S’s as a 24-hour behavioral framework: standing, stepping, sweating, strengthening, and sleep. This expands lifestyle care beyond structured exercise to sedentary-time interruption, daily movement, resistance training, sleep quantity, quality, and timing. It is paired with stronger attention to Mediterranean-style eating patterns, individualized MNT, caution with ketogenic diets and intermittent fasting when medications raise hypoglycemia or ketoacidosis risks, and the continued conclusion that supplements are not recommended for glycemic management.
CGM is recommended for consideration, particularly in insulin-treated type 2 diabetes; automated insulin delivery has emerging but still limited evidence. The update also stresses that technology should supplement—not replace—DSMES, individualized support, and equitable access. The consensus specifically identifies an updated 24-hour behavioral framework and a revised medication algorithm among its major changes.
What remains cautious
Despite its proactive direction, the report does not claim that all unresolved questions have been settled. It identifies evidence gaps in optimal sequencing or routine combination of SGLT2 inhibitors and GLP-1–based therapies; long-term weight-maintenance strategies; use of GLP-1–based therapy where weight loss is undesirable; targets based on CGM; treatment in youth, pregnancy, frailty, and underrepresented racial and ethnic groups; and clinically useful definitions of diabetes remission.
The updated report’s central message is therefore not “newer drugs for everyone.” It is that type 2 diabetes should be managed earlier and more comprehensively, with treatment selected to modify the individual’s actual disease burden and future risk—not HbA1c in isolation. The remaining implementation challenge is translating that model into accessible DSMES, multidisciplinary care, equitable medicine access, complication surveillance, and timely treatment adjustment.
Source: American Diabetes Association
