Changes to consensus recommendations

  • We previously recommended that, in the setting of type 2 diabetes, established CVD was a compelling indication for treatment with a GLP-1 receptor agonist or SGLT2 inhibitor. We now further suggest the following:

  • General consideration

    • • In appropriate high-risk individuals with established type 2 diabetes, the decision to treat with a GLP-1 receptor agonist or SGLT2 inhibitor to reduce MACE, hHF, CV death, or CKD progression should be considered independently of baseline HbA1c or individualized HbA1c target.

    • • Providers should engage in shared decision making around initial combination therapy in new-onset cases of type 2 diabetes.

  • GLP-1 receptor agonist recommendations

    • • For patients with type 2 diabetes and established atherosclerotic CV disease (such as those with prior myocardial infarction, ischemic stroke, unstable angina with ECG changes, myocardial ischemia on imaging or stress test, or revascularization of coronary, carotid, or peripheral arteries) where MACE is the gravest threat, the level of evidence for MACE benefit is greatest for GLP-1 receptor agonists.

    • • To reduce risk of MACE, GLP-1 receptor agonists can also be considered in patients with type 2 diabetes without established CVD with indicators of high risk, specifically, patients aged 55 years or older with coronary, carotid, or lower extremity artery stenosis >50%, left ventricular hypertrophy, eGFR <60 mL min–1 [1.73 m]–2, or albuminuria.

  • SGLT2 inhibitor recommendations

    • • For patients with or without established atherosclerotic CVD, but with HFrEF (EF <45%) or CKD (eGFR 30 to ≤60 mL min–1 [1.73 m]–2 or UACR >30 mg/g, particularly UACR >300 mg/g), the level of evidence for benefit is greatest for SGLT2 inhibitors.

    • • SGLT2 inhibitors are recommended in patients with type 2 diabetes and HF, particularly those with HFrEF, to reduce hHF, MACE, and CV death.

    • • SGLT2 inhibitors are recommended to prevent the progression of CKD, hHF, MACE, and CV death in patients with type 2 diabetes with CKD.

    • • Patients with foot ulcers or at high risk for amputation should only be treated with SGLT2 inhibitors after careful shared decision making around risks and benefits with comprehensive education on foot care and amputation prevention.