The 2026 Diabetes Consensus Backs GLP-1 or SGLT2 Drugs Early, Possibly From Diagnosis, Without Waiting on Metformin

Since 2006, the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) have written a joint report that tells clinicians how to treat type 2 diabetes in adults. The 2022 edition was titled "Management of Hyperglycemia in Type 2 Diabetes." The new edition, published on October 2, 2026, in the journals Diabetes Care and Diabetologia, is titled "Management of Type 2 Diabetes." Hyperglycemia means high blood sugar, and dropping it from the title sums up the update.

The authors write that they have widened their focus from blood sugar to the whole disease, including the long-term conditions that often come with it, such as heart failure and fatty liver disease. In practice, that means a push to start two newer drug families early, possibly at diagnosis, because large trials have shown that they protect the heart and kidneys. Our October 2 digest covered the release on the last day of the EASD meeting in Milan.

A 16-member writing group, led by Melanie Davies of the University of Leicester and John Buse of the University of North Carolina, searched for trials and analyses published from May 2022 through December 2025. A draft went out for public comment at the ADA's June 2026 meeting in New Orleans. The final text passed outside peer review and was approved by committees at the ADA and the EASD, which paid for the work.

The report is written for diabetes care teams in the U.S. and Europe, and it has no legal force. Drug labels still come from regulators such as the FDA, and your insurance plan still decides what it covers. The authors also write that the advice reflects "the values and preferences of the consensus group, acknowledging limitations in the evidence base." Many of the authors, including both chairs, list paid consulting or advisory work for Eli Lilly and Novo Nordisk, which make the leading GLP-1-based drugs.

SGLT2 inhibitors are pills, such as empagliflozin (Jardiance) and dapagliflozin (Farxiga), that lower blood sugar by making the kidneys pass extra glucose into the urine. The report uses "GLP-1-based therapies" for two groups. One is GLP-1 receptor agonists such as semaglutide (Ozempic, or the Rybelsus pill) and dulaglutide (Trulicity). The other is tirzepatide (Mounjaro), which acts on both GLP-1 and GIP hormone receptors.

The key sentence says most people with type 2 diabetes "would benefit from early introduction of an SGLT2 inhibitor or/and GLP-1-based therapy, potentially from diagnosis." The report calls both families "first-line therapeutic considerations" and says their heart benefits do not depend on metformin. For people who already have heart disease, a GLP-1-based drug with proven benefit should be used to cut heart attacks, strokes, and deaths. An SGLT2 inhibitor is the other choice, cutting those events plus heart failure and protecting the kidneys. When heart disease, kidney disease, and heart failure occur together, it says to consider starting both early.

Earlier does not mean the same plan for everyone. The report ties treatment to each person's "absolute cardio-kidney risk and time horizon." A drug that cuts risk by the same percentage prevents more heart attacks in a group that has many than in a group that has few. For people with only mildly high blood sugar, little extra weight, and no organ damage, or with limited life expectancy, the authors say a slower, step-by-step approach may fit.

Metformin has long been the default first pill, and the report lists the reasons. It lowers HbA1c, a blood test that reflects average blood sugar over the past two to three months. It rarely causes low blood sugar on its own, does not add weight, has a good safety record, and costs little. What changed is the evidence that the newer drugs protect the heart and kidneys whether or not someone takes metformin. The authors add a caveat: those data come "from subgroup analyses not protected by randomisation so the evidence is not definitive, and some may prefer to continue metformin."

So metformin stays in the toolkit. The report says it still has value for many people and should be kept, along with SGLT2 inhibitors and GLP-1-based drugs, when someone starts insulin. Its drug table rates metformin's cost as low and the cost of both newer families as high.

One line gives weight equal billing with glucose: "Developing weight targets (achieved by any means) are as essential in diabetes management as glycaemic targets." Losing at least 5% of body weight helps many people, the authors write, and the report ties losses of 10–15% to changing the course of the disease and, for some people, remission. For people with overweight or obesity, it says glucose-lowering drugs that also lower weight should be preferred, and metabolic surgery should be considered.

Big weight loss brings two more pieces of advice. People losing weight with GLP-1-based drugs or surgery should get guidance on eating enough protein and doing strength training, to help limit loss of lean mass. And because trials show weight returns when GLP-1-based therapy stops, the report suggests ways to keep it off, including tapering to a lower maintenance dose.

On blood sugar, the report calls an HbA1c target of around 6.5% to 7% or lower reasonable for most nonpregnant adults with about 10 years of life ahead. It suggests 6.5% or lower for people diagnosed before age 40 and for people whose treatment carries no risk of low blood sugar. Looser targets can suit people who are frail or have limited life expectancy. The authors also admit that trial evidence for targets below 7% "is poorly developed."

The report also names drugs for specific conditions. SGLT2 inhibitors should be used in heart failure. For people with obesity and HFpEF, a form of heart failure in which the heart pumps normally but is too stiff to fill well, semaglutide or tirzepatide should be used to ease symptoms. In chronic kidney disease, an SGLT2 inhibitor should be started and kept until dialysis or a transplant is needed, and a GLP-1-based drug should be started too. A drug such as finerenone (Kerendia) should be added when urine tests show raised albumin. Semaglutide already has an approval for slowing kidney disease.

MASLD, short for metabolic dysfunction-associated steatotic liver disease, is fat buildup in the liver tied to problems such as obesity and high blood sugar. The report says it affects more than 70% of people with type 2 diabetes, and that people who also have obesity should get a GLP-1-based drug with proven benefit. Losing at least 5% of body weight reduces liver fat, and losing 7–10% is linked to clearing MASH, the inflamed form. For people with obesity and sleep apnea, tirzepatide or a GLP-1 receptor agonist could be prioritized, though the report says CPAP remains the standard treatment and drugs should add to it.

The ADA's press release adds mental health conditions such as anxiety and depression, as well as gum health, to the list of conditions worth checking. The report also suggests looking for hidden causes, such as excess cortisol, when blood sugar stays high despite several drugs. It says excess cortisol may be tied to high blood sugar in about a quarter of people in that situation.

For GLP-1-based therapies, the most common side effects are nausea, vomiting, diarrhea, and constipation, which tend to appear when starting or raising the dose and fade over time. The report says slower dose increases can help. Because fast drops in blood sugar may worsen diabetic eye disease, it recommends eye checks before and during treatment. In heart-outcome trials, GLP-1 receptor agonists did not raise rates of pancreatitis, pancreatic cancer, or medullary thyroid cancer, though gallbladder problems were more common, especially at higher doses.

SGLT2 inhibitors raise the risk of genital yeast infections, which the report calls typically mild and treatable. They can also cause diabetic ketoacidosis, a dangerous buildup of acids in the blood, but it is rare: 0.1–0.6% of people in heart-outcome trials, against under 0.1–0.3% on placebo. The report's drug table advises stopping them three to four days before planned surgery. For women who could become pregnant, it calls for counseling on birth control, since GLP-1-based therapies are not recommended in pregnancy.

A consensus report cannot lower a copay. The report rates both newer drug families as high cost, says cost and access barriers "are being mitigated in many countries, related to patent expirations and market forces," and calls for regulatory and payment reform in most health systems. Where money is tight, it says the highest-risk patients may need to come first. Among U.S. employers, coverage for diabetes is far more common than coverage for weight loss: a survey published in July 2026 by the International Foundation of Employee Benefit Plans found that 60% cover GLP-1 drugs for diabetes only and another 36% cover them for both. Our guides to employer coverage and the 2026 price deals walk through out-of-pocket costs.

Questions worth bringing to your next appointment:

• Given my heart and kidney risk, would I benefit from an SGLT2 inhibitor, a GLP-1-based drug, or both?
• What HbA1c target and weight-loss goal make sense for me?
• If I take metformin, should I keep it when I add a newer drug?
• Should I get a urine albumin test, a liver check, or a sleep apnea evaluation?
• If my blood sugar stays high on several drugs, should we look for another cause?
• What will my plan charge, and does it require prior authorization?

The report ends with a list of gaps. The authors write that there is still no compelling evidence on whether GLP-1-based drugs and SGLT2 inhibitors should be routinely combined, or in which order to add them. Most GLP-1 trials enrolled people with overweight or obesity, so it is unclear how to use these drugs in people who should not lose weight; for now, the report says dulaglutide may be preferred for them. Pregnancy is another gap, since stopping a GLP-1-based drug can bring weight gain and worse blood sugar, and the authors write that "further study is desperately needed." They also ask how to keep lost weight off and how to protect muscle and bone during treatment.