International Expert Panel Issues New Guidelines for SGLT-2 and GLP-1 Use in Type 2 Diabetes Based on Cardiovascular Risk
核心洞察
An international expert panel recommends SGLT-2 inhibitors (搜索) and GLP-1 receptor agonists for almost all adults with type 2 diabetes (搜索) at high cardiovascular and kidney risk, based on analysis of nearly 500,000 patients across 869 randomized trials.
The guidelines suggest these medications for moderate-risk patients but advise against routine use in lower-risk individuals, emphasizing a risk-stratified approach to diabetes management.
The recommendations prioritize preventing cardiovascular and kidney complications over blood sugar control alone, reflecting a shift in diabetes treatment paradigm toward comprehensive organ protection.
An international panel of experts has issued comprehensive new guidelines recommending sodium-glucose cotransporter-2 (SGLT-2 (搜索)) inhibitors and glucagon-like peptide-1 (GLP-1 (搜索)) receptor agonists for most adults with type 2 diabetes (搜索) who face moderate to high cardiovascular and kidney risks. The recommendations, published in The BMJ, represent a significant shift toward risk-stratified diabetes management focused on preventing complications rather than solely controlling blood sugar.
The guidelines emerge as type 2 diabetes (搜索) affects nearly half a billion individuals globally and ranks as the ninth leading cause of death internationally. The central goal of diabetes management has evolved from controlling blood glucose to preventing cardiovascular and kidney complications, with SGLT-2 inhibitors (搜索) and GLP-1 receptor agonists demonstrating protective benefits for the heart and kidney while achieving significant weight loss.
Evidence-Based Risk Stratification Approach
The international panel, which included patient partners, clinicians, and methodologists, developed the guidelines following standards for trustworthy recommendations using the GRADE approach. Their analysis considered the balance of benefits, harms, and burdens from the patient's perspective through a living systematic review and network meta-analysis evaluating treatments as of July 31, 2024.
The comprehensive evaluation included data from almost half a million individuals with type 2 diabetes (搜索) across 869 randomized controlled trials, involving 63 medications and 26 outcomes. This extensive evidence base informed six specific recommendations for SGLT-2 (搜索) inhibitor and GLP-1 (搜索) receptor agonist use.
Risk-Based Treatment Recommendations
For adults at lower risk of cardiovascular and kidney complications, the panel suggests against using SGLT-2 inhibitors (搜索) or GLP-1 receptor agonists. This recommendation was informed by evidence from 110 trials involving 89,803 participants for SGLT-2 inhibitors and 109 trials involving 102,687 participants for GLP-1 receptor agonists.
In contrast, for adults at moderate risk of cardiovascular and kidney complications, the panel suggests using both GLP-1 receptor agonists and SGLT-2 inhibitors (搜索), based on similar trial data demonstrating meaningful benefits that outweigh potential risks.
The strongest recommendation applies to adults at higher risk of cardiovascular and kidney complications, where the panel recommends using SGLT-2 inhibitors (搜索) or GLP-1 receptor agonists. This recommendation draws from evidence across 219 trials involving nearly 199,000 participants, where treatments showed important, high-certainty benefits for overall survival, cardiovascular health, and kidney function that clearly outweigh risks and treatment burdens.
Specialized Recommendations for Specific Conditions
For adults with chronic kidney disease (搜索) (CKD) at moderate risk, the panel suggests against using finerenone (Kerendia; Bayer). This weak recommendation, based on evidence from two clinical trials with 13,026 participants, reflects finerenone's limited benefits, potential for harm, cost considerations, access issues, and limited clinical experience.
However, for adults with CKD at the highest risk of cardiovascular and kidney complications, the panel suggests using finerenone. Despite being a weak recommendation based on two trials, treatment with finerenone demonstrated potential survival and kidney benefits that outweigh the risks in this high-risk population.
For adults with obesity (搜索), the panel favors using tirzepatide (Mounjaro, Zepbound; Eli Lilly and Company). When choosing between different GLP-1 receptor agonists and tirzepatide, healthcare providers should weigh the higher certainty of cardiovascular and kidney benefits demonstrated in clinical trials.
Clinical Implementation and Patient-Centered Care
The panel emphasized that healthcare providers must first assess an individual's risk based on risk stratification tools and include patients in shared decision-making processes. For patients with lower risk of complications, the guidelines advise discussing other available treatment options based on the patient's preferences and priorities rather than routinely prescribing these newer medications.
Current clinical practice already recognizes SGLT-2 inhibitors (搜索) as protective agents, with many guidelines indicating they represent a standard of care for cardiovascular, renal, and metabolic protection in individuals with type 2 diabetes (搜索). These medications provide primary and secondary preventive actions beyond their glucose-lowering benefits, offering clinicians tools to address macrovascular complications that were previously difficult to prevent.
Evolving Treatment Paradigm
The guidelines reflect rapidly evolving evidence around SGLT-2 inhibitors (搜索) and GLP-1 receptor agonists for diabetes and cardiovascular treatment. While metformin remains the drug of choice for patients with type 2 diabetes (搜索) according to major guidelines, adding an SGLT-2 (搜索) inhibitor is considered prudent because of systemic benefits, especially when a patient's cardiovascular risk equals or exceeds 10% or when kidney function is compromised.
The recommendations acknowledge that SGLT-2 inhibitors (搜索)' glycemic benefits are reduced once estimated glomerular filtration rate falls below 45 mL/min/1.73 m², though their preventive actions remain durable. This distinction between glucose-lowering and organ-protective effects underscores the complexity of modern diabetes management and the need for individualized treatment approaches based on comprehensive risk assessment.