ADA 2026 Standards Elevate Cardiorenal Risk Reduction to Co-Primary Goal, Recommend Earlier GLP-1 and SGLT-2 Use
Key Insights
The 2026 ADA Standards of Care formally reposition cardiovascular and kidney risk reduction as coequal priorities alongside glucose lowering, no longer treating them as secondary goals.
GLP-1 receptor agonists (search) and SGLT-2 inhibitors (search) are now explicitly recommended for consideration from the time of type 2 diabetes (search) diagnosis as disease-modifying therapies.
The holistic care framework expands beyond cardiovascular and kidney disease to include fatty liver disease, cognitive dysfunction, and osteoarthritis, with finerenone recognized for heart failure (search) outcomes.
The 2026 American Diabetes Association (search) (ADA) Standards of Care introduce a fundamental reorientation in type 2 diabetes (search) management: cardiovascular and kidney risk reduction are now formally positioned as co-primary treatment goals alongside glucose lowering. This shift, described by experts involved in drafting the guidance, carries significant implications for how pharmacists and clinicians approach medication therapy management in patients with diabetes.
"The most meaningful evolution is that cardiovascular and kidney risk reduction is no longer treated as secondary to glucose lowering," said Dave Dixon, PharmD, FACC, FAHA, FCCP, FNLA, BCACP, CLS, professor and chair of the Department of Pharmacotherapy and Outcomes Science at Virginia Commonwealth University School of Pharmacy, who served as a subject matter expert on the Cardiovascular Disease and Risk Management section.
GLP-1 and SGLT-2 Inhibitors (search) as Disease-Modifying Therapies
The updated guidance explicitly recommends that glucagon-like peptide-1 (GLP-1) receptor agonists and sodium-glucose cotransporter 2 (SGLT-2 (search)) inhibitors should be considered from the point of type 2 diabetes (search) diagnosis, reflecting their classification as disease-modifying agents rather than add-on options reserved for later stages of disease.
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, emphasized the significance of this shift during the 2026 ADA Scientific Sessions. "There's a call for more routine and earlier use of GLP-1 receptor agonists (search) and SGLT-2 inhibitors (search)—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," Buse said.
The strength of this recommendation scales with a patient's cardiovascular and cardiorenal risk profile. Buse noted that for individuals diagnosed after a myocardial infarction, "the rationale for using a GLP-1 receptor (search) agonist or an SGLT-2 (search) inhibitor, or both, is much, much stronger" than for lower-risk patients. In people at high risk of or with established cardiovascular disease, the guidance explicitly states they should receive a GLP-1 receptor agonist with proven cardiovascular benefit, an SGLT-2 inhibitor with proven cardiovascular benefit, or both.
Expanded Holistic Care Framework
The 2026 guidance broadens the holistic care framework beyond cardiovascular disease and chronic kidney disease (search) (CKD) to encompass metabolic dysfunction-associated steatohepatitis (MASH), metabolic dysfunction-associated fatty liver disease (MASLD), cognitive dysfunction, and osteoarthritis. For MASH and MASLD, the guidance expresses a preference for GLP-1 receptor agonists (search), with consideration of SGLT-2 inhibitors (search), high-dose semaglutide (Ozempic, Wegovy; Novo Nordisk), and the thyroid hormone receptor agonist resmetirom (Rezdiffra; Madrigal Pharmaceuticals).
For the first time, the document incorporates non-glucose-lowering agents into individualized care considerations. Finerenone (Kerendia; Bayer (search)), a non-steroidal mineralocorticoid antagonist, received recognition for its favorable heart failure (search) outcomes in patients with diabetes, particularly those with an ejection fraction of 40% or greater. Dixon noted that finerenone "has favorable benefits in patients with diabetes in terms of improving heart failure outcomes."
Updated Blood Pressure Targets
The guidance maintains the blood pressure goal of less than 130/80 mmHg but now includes encouragement to achieve systolic blood pressure below 120 mmHg in patients where feasible. Dixon explained this update is "based on a couple of recent trials that have demonstrated improved outcomes in patients with diabetes while having a modest risk of adverse effects."
Reframing Pharmacist-Patient Conversations
Dixon emphasized that pharmacists should reframe medication therapy management discussions around cardiorenal protection rather than glucose control alone. "These conversations should really be reframed and focused on cardiovascular and kidney protection," he said. "Certainly A1C control is important, and we want to encourage that. We also want our patients to understand that that's not the end, and ultimately we want to reduce their risk of cardiovascular and kidney disease."
Pharmacists are uniquely positioned to help patients understand that SGLT-2 inhibitors (search) and GLP-1–based therapies "not only do they improve glucose control, but they modify that long-term risk of cardiovascular and kidney disease," Dixon added.
Patient-Centered Decision-Making and Preliminary Status
The guidance includes strong patient-centered language, with Buse noting that "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."
Buse cautioned that the document remains preliminary. "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," he said. The final document is anticipated for release at the European Association for the Study of Diabetes (EASD) meeting in Milan in September.