New Type 2 Diabetes Guidance Ties Treatment Choice to Cardio-Renal Risk

With T2D significantly associated with multiorgan morbidity and representing the ninth leading cause of death, preventing CV and kidney complications is a high priority.

SGLT2 inhibitors and GLP-1 RAs, along with finerenone, a nonsteroidal selective mineralocorticoid RA, and tirzepatide, a dual glucose-dependent insulinotropic polypeptide/GLP-1 RA, have transformed the management of T2D in recent years.

However, with evidence rapidly advancing regarding which drugs or drug combinations are most effective for the prevention of complications in specific patient types, the need for living guidelines to continuously provide updates on emerging evidence was deemed necessary.

The guideline, created by an international panel of clinicians, methodologists, and two patient partners, is based on a systematic review and network meta-analysis of evidence from nearly half a million adults with T2D across 869 randomized controlled trials, involving 63 medications and 26 outcomes.

In assessing the data to determine the benefits of the four key medications for adults with T2D based on their risk level for CV and kidney-related complications, the panel concluded that:

  1. For patients at higher risk, defined as having established CV disease (CVD) and/or chronic kidney disease (CKD) with high risk for complications, or established heart failure, the use of SGLT2 inhibitors or GLP-1 RAs for treatment is strongly recommended, with a weak recommendation in favor of the use of finerenone in adults with CKD.

    “The cardiovascular and kidney benefits of GLP-1s are independent of significant reductions in weight,” Vandvik noted. “These benefits are more or less equal to those of SGLT2 inhibitors, meaning that patients at moderate to highest risk should be offered one of these drugs for cardiorenal protection,” he said.

  2. For patients at moderate risk, defined as having more than three CV risk factors without established CVD or CKD or established CVD and/or CKD at a lower risk for complications, the panel issued a weak recommendation in favor of treatment with SGLT2 inhibitors or GLP-1 RAs, while making a weak recommendation against the use of finerenone in adults with CKD.

  3. For those at lower risk, defined as having three or fewer CV risk factors without established CVD or CKD, the panel issued a weak recommendation against the use of SGLT2 inhibitors or GLP-1 RAs.

    “[In low-risk patients], the benefits are not considered to outweigh the harms and burdens of the drugs,” Vandvik said. “Experts did not find drugs clinically effective [in those patients], and they will also represent a waste of precious health resources for patients and society.”

  4. Across all levels of risk, the panel issued a weak recommendation supporting the use of tirzepatide in adults with obesity.

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