In an interview with Pharmacy Times at the 2026 American Diabetes Association (ADA) Scientific Sessions, John B. Buse, MD, PhD, Verne S. Caviness Distinguished Professor of Medicine at the University of North Carolina–Chapel Hill School of Medicine’s Division of Endocrinology and Metabolism, discussed key updates to the American Diabetes Association’s (ADA’s) Standards of Care guidance on the management of hyperglycemia. Buse highlighted a significant philosophical shift toward earlier and more routine use of glucagon-like peptide-1 (GLP-1) receptor agonists and sodium-glucose cotransporter 2 (SGLT-2) inhibitors, noting that the updated guidance explicitly recommends considering these agents from the point of a type 2 diabetes (T2D) diagnosis, given their role as disease-modifying therapies. He emphasized that the strength of this recommendation scales with a patient’s cardiovascular and cardiorenal risk profile.
Buse also outlined the document’s expanded holistic care framework, which now extends beyond cardiovascular disease and chronic kidney disease (CKD) to include metabolic dysfunction-associated steatohepatitis (MASH), metabolic dysfunction-associated fatty liver disease (MASLD), cognitive dysfunction, and osteoarthritis. For the first time, the guidance incorporates non-glucose-lowering agents such as finerenone (Kerendia; Bayer) into individualized care considerations. Buse underscored the document’s strong patient-centered language, noting that treatment decisions must account for individual values, preferences, and economic factors. He cautioned that the guidance is still in a preliminary state and may change following peer review and approval from both the ADA and the European Association for the Study of Diabetes (EASD) ahead of its anticipated final release at the EASD meeting in Milan in September.
Pharmacy Times: What are the most consequential updates in the new ADA/EASD consensus statement that pharmacists need to understand when counseling and managing patients with type 2 diabetes?
John B. Buse, MD, PhD Well, that’s a great question. The ADA Standards of Care guidance on the management of hyperglycemia—the last time it came out, in 2022, also here at the ADA meeting—for the first time we started to talk about holistic care, so it’s more than just glucose management. Here, there is a further expansion of holistic care for people living with T2D to not only include cardiovascular disease management and sort of using disease-modifying therapies like GLP-1 receptor agonists and SGLT-2 inhibitors for cardiovascular disease and a bit more detail about heart failure as a condition, as well as CKD, but also branching to further areas—fatty liver disease and mentions of cognitive dysfunction and osteoarthritis and other areas where these drugs have been shown to have benefits.
Beyond that, there’s a call for more routine and earlier use of GLP-1 receptor agonists and SGLT-2 inhibitors—quite explicitly, a suggestion that GLP-1 receptor agonists and/or SGLT-2 inhibitors should be considered from the diagnosis of diabetes, with the idea that they’re disease-modifying agents. And obviously, if someone is diagnosed after a heart attack—so they went to the emergency room with chest pain, and during that hospitalization they were discovered to have diabetes—the rationale for using a GLP-1 receptor agonist or an SGLT-2 inhibitor, or both, is much, much stronger than, say, a 24-year-old laborer who goes to the emergency room because he has an infection on his hand and they just check an A1C and make the diagnosis of diabetes there. One might quibble about whether a GLP-1 receptor agonist or an SGLT-2 inhibitor is the ideal drug or not, but what we’re suggesting is that you should at least consider it. And personally, as just one member of the writing group, if I were diagnosed with diabetes—or my child were diagnosed with diabetes—I do think the logical first drug therapy would be a GLP-1 receptor agonist or SGLT-2 inhibitor.
Key Takeaways
- Earlier initiation of GLP-1 receptor agonists and SGLT-2 inhibitors is now explicitly recommended. The updated ADA hyperglycemia guidance suggests these agents should be considered at the time of T2D diagnosis, reflecting their classification as disease-modifying therapies rather than add-on options.
- The ADA’s holistic care framework has expanded considerably. Beyond cardiovascular disease and CKD, the 2026 guidance now addresses fatty liver disease, cognitive dysfunction, and osteoarthritis and incorporates non-glucose-lowering agents like finerenone into individualized treatment planning.
- The guidance remains preliminary. The document represents a first reveal and will undergo peer review by both the ADA and EASD before its final publication.
I think those are the sort of shifts. Nothing revolutionary; it’s only been 4 years. We have more effective drugs now than we had in 2022 when we were writing the last one, but there haven’t been revolutionary advances that demand revolutionary change. This is incremental and more of a shift in understanding. But if you look back 6 years ago, very explicitly the guidance was: you’re diagnosed with diabetes, it’s lifestyle therapy and metformin—that’s the first-line therapy. And if you look back 20 years ago, when we had the first of these, this was inconceivable—that diabetes care would have evolved in this way. It’s exciting to have been involved over the last 20 years in these guidelines.
One really important caveat: this is a first reveal of the document. It will undergo peer review and review by the responsible committees at the ADA and at the EASD, and it is quite possible through that process that there will be changes. So what I’m telling you today may not turn out to be true when the final document comes out in association with the EASD meeting in Milan in September.
Pharmacy Times: How should clinicians and care teams be thinking about individualizing hyperglycemia management, particularly as the treatment landscape continues to expand with newer drug classes?
Buse: Yeah, and that’s a great question—and kind of complicated to get the words exactly right in just a few minutes. But in this document there is very clear language around patient-centeredness, so the decisions that we as providers make need to be in concert with the people living with diabetes, taking into account their values and preferences and issues like economics and medical factors. So it involves a lot of inputs into that decision-making.
But as an example, in people at high risk of cardiovascular disease or with established cardiovascular disease, quite explicitly the language is that they should be on a GLP-1 receptor agonist with proven cardiovascular benefit, or an SGLT-2 inhibitor with proven cardiovascular benefit, or both. And for instance, in heart failure with preserved ejection fraction, similarly, those are the kinds of choices. For drugs in people with reduced ejection fraction, there is a preference for SGLT-2 inhibitors. In CKD, SGLT-2 inhibitors and/or GLP-1 receptor agonists. In MASH and MASLD, a preference for GLP-1 receptor agonists and consideration of SGLT-2 inhibitors, high-dose semaglutide (Ozempic, Wegovy; Novo Nordisk), and the thyroid hormone receptor agonist resmetirom (Rezdiffra; Madrigal Pharmaceuticals) are considerations.
There’s a lot of detail. Again, there’s discussion now—for the first time—of drugs like finerenone and other agents being not glucose-lowering agents but ones that need to be part of the thought process in individualizing care. They’re not directed at lowering glucose; they’re directed at improving outcomes in individuals with particular conditions.
