What is the current 2026 update in diabetes management?

Current 2026 Updates in Diabetes Management

The most significant paradigm shift in diabetes management is the move toward organ-protection-first therapy, where SGLT2 inhibitors and GLP-1 receptor agonists are now prioritized based on cardiovascular and kidney disease status independent of HbA1c levels or metformin use. 1

Cardiorenal-First Treatment Algorithm

For Patients with Established Cardiovascular Disease

• Use a GLP-1 receptor agonist with proven cardiovascular benefit as first-line therapy to reduce major adverse cardiovascular events (MACE), particularly when atherosclerotic disease is the primary concern. 1
• Alternatively, use an SGLT2 inhibitor with proven benefit to reduce both MACE and heart failure hospitalizations while improving kidney outcomes. 1
• These decisions should be made independent of baseline HbA1c, current HbA1c target, or whether the patient is on metformin. 1

For Patients with Heart Failure

• SGLT2 inhibitors are mandatory in patients with heart failure, especially those with reduced ejection fraction (EF <45%), to reduce hospitalizations, MACE, and cardiovascular death. 1
• This recommendation applies regardless of glycemic control status. 1

For Patients with Chronic Kidney Disease

• For eGFR ≥20 mL/min/1.73 m² with albuminuria >30 mg/g (particularly >300 mg/g), initiate an SGLT2 inhibitor with proven kidney benefit to prevent CKD progression, reduce heart failure, and decrease MACE. 1
• If SGLT2 inhibitors are not tolerated or contraindicated, use a GLP-1 receptor agonist with proven cardiovascular benefit and continue until kidney replacement therapy is needed. 1
• For persistent albuminuria despite maximum tolerated RAS inhibitor and SGLT2 inhibitor therapy, add a nonsteroidal mineralocorticoid receptor antagonist (MRA) if eGFR ≥25 mL/min/1.73 m² and potassium is consistently normal. 1

For High-Risk Patients Without Established Disease

• In patients aged ≥55 years with multiple cardiovascular risk factors (obesity, hypertension, smoking, dyslipidemia, or albuminuria), use either a GLP-1 receptor agonist or SGLT2 inhibitor with proven cardiovascular benefit. 1
• GLP-1 receptor agonists can be considered for patients without established CVD but with high-risk indicators including coronary/carotid/peripheral artery stenosis >50%, left ventricular hypertrophy, eGFR <60 mL/min/1.73 m², or albuminuria. 1

Glycemic Monitoring Evolution

HbA1c Limitations in Advanced CKD

• HbA1c accuracy declines significantly in CKD stages G4-G5 and is unreliable in dialysis patients. 1
• Use glucose management indicator (GMI) derived from continuous glucose monitoring (CGM) when HbA1c is discordant with measured glucose or clinical symptoms. 1
• Monitor HbA1c twice yearly for stable patients, increasing to quarterly when targets are not met or after therapy changes. 1

CGM Integration

• Daily glycemic monitoring with CGM or self-monitoring prevents hypoglycemia and improves control when using medications with hypoglycemia risk. 1
• For patients declining daily monitoring, prioritize glucose-lowering agents with lower hypoglycemia risk and dose appropriately for eGFR. 1

Combination Therapy Strategies

Triple Therapy for High-Risk CKD

• Nonsteroidal MRAs can be added to RAS inhibitors and SGLT2 inhibitors for patients with type 2 diabetes, eGFR ≥25 mL/min/1.73 m², normal potassium, and persistent albuminuria. 1
• Select patients with consistently normal potassium and monitor regularly after initiation to mitigate hyperkalemia risk. 1

Early Combination in Young Patients

• In patients <40 years old with diabetes, consider early combination therapy rather than sequential monotherapy escalation. 1
• Engage in shared decision-making around initial combination therapy for new-onset type 2 diabetes. 1

Avoiding Ineffective Combinations

• Never combine DPP-4 inhibitors with GLP-1 receptor agonists—this provides no additional HbA1c reduction beyond GLP-1 receptor agonist monotherapy while increasing cost and medication burden. 2
• When adding SGLT2 inhibitors to sulfonylureas, reduce the sulfonylurea dose by 50% immediately to prevent severe hypoglycemia. 3

Lifestyle and Nutrition Updates

Dietary Recommendations for CKD

• Maintain protein intake at 0.8 g/kg/day for diabetes with CKD not on dialysis. 1
• Patients on hemodialysis or peritoneal dialysis should consume 1.0-1.2 g/kg/day. 1
• Limit sodium intake to <2 g/day (<90 mmol/day or <5 g sodium chloride/day). 1
• Emphasize vegetables, fruits, whole grains, fiber, legumes, plant-based proteins, unsaturated fats, and nuts while reducing processed meats, refined carbohydrates, and sweetened beverages. 1

Physical Activity

• Advise moderate-intensity physical activity for at least 150 minutes per week cumulative duration, or to the level compatible with cardiovascular and physical tolerance. 1

Critical Safety Considerations

SGLT2 Inhibitor Precautions

• Educate patients about euglycemic diabetic ketoacidosis risk—instruct them to seek immediate care for nausea, vomiting, abdominal pain, or generalized weakness. 3
• Counsel about increased genital mycotic infection risk and advise meticulous hygiene. 3
• For patients with foot ulcers or high amputation risk, use SGLT2 inhibitors only after careful shared decision-making with comprehensive foot care education. 1

Hypoglycemia Prevention

• SGLT2 inhibitors combined with sulfonylureas increase hypoglycemia risk by approximately 50% compared to monotherapy. 3
• Monitor glucose more frequently during the first 2-4 weeks after initiating combinations. 3

Special Populations

• In women of reproductive potential, provide contraception counseling and avoid medications that may adversely affect the fetus. 1
• Selection of cardiovascular and kidney outcome medications should not differ for older adults. 1
• Tobacco cessation is mandatory for all patients with diabetes and CKD. 1

Integrated Care Framework

Diabetes management must be holistic, multifactorial, and account for the lifelong nature of the disease with the person living with diabetes at the center of care. 1

The healthcare team should include primary care providers, diabetologists, diabetes educators, dietitians, pharmacists, nurses, and specialists (cardiologists, nephrologists, mental health providers, podiatrists, ophthalmologists) as needed. 1

Technology now serves as an essential tool to enhance communication, support, and monitoring between patients and healthcare teams. 1

Language matters in diabetes care—communication must be empathic, person-centered, and informed by understanding of local resources and individual social determinants of health. 1