New JAMA review updates type 2 diabetes care with risk-based treatment, emphasizing early SGLT2i/GLP-1RA use, comorbidities, and personalized glycemic goals.
A new clinical review outlines updated recommendations for diagnosing and managing type 2 diabetes in adults, with an emphasis on personalized treatment based on comorbidities and individual risk factors.
Type 2 diabetes accounts for 90% to 95% of diabetes cases globally and affected an estimated 589 to 828 million people between 2022 and 2024. In the United States, approximately 15.8% of adults have the disease.
The condition is marked by progressive loss of insulin secretion in the setting of insulin resistance. Most individuals are asymptomatic at diagnosis, making routine screening essential. Diagnostic thresholds include hemoglobin A1C ≥6.5%, fasting plasma glucose ≥126 mg/dL, or 2-hour plasma glucose ≥200 mg/dL during a 75-g oral glucose tolerance test. Diagnosis typically requires two abnormal results unless symptoms and severe hyperglycemia are present.
Metformin remains a first-line therapy, but guidelines now recommend early use of sodium-glucose cotransporter 2 inhibitors (SGLT2is) or glucagon-like peptide-1 receptor agonists (GLP-1RAs) for individuals with atherosclerotic cardiovascular disease, heart failure, or chronic kidney disease. These agents demonstrated added cardiovascular and renal benefits independent of glycemic control. A meta-analysis of six SGLT2i trials reported a 10% relative reduction in major adverse cardiovascular events (MACE), and a similar analysis of seven GLP-1RA trials found a 12% MACE reduction.
Lifestyle interventions remain central to management. Physical activity reduced A1C by 0.4% to 1.0%, with optimal benefits seen at approximately 244 minutes per week of moderate-intensity aerobic activity. Medical nutrition therapy provided by a registered dietitian and diabetes self-management education were associated with A1C reductions of 0.3% to 2% and 0.6%, respectively. The DiRECT trial reported that 46% of participants achieved diabetes remission at 12 months following a very low-calorie diet and stepped food reintroduction.
Weight loss continues to be a critical treatment goal. High-potency GLP-1RAs and dual glucose-dependent insulinotropic polypeptide/GLP-1RAs, such as tirzepatide, were associated with A1C reductions up to 2.5% and weight loss exceeding 5% in most individuals, with some experiencing losses greater than 10%.
For individuals who did not reach glycemic targets with oral agents, guidelines recommend starting a GLP-1RA prior to initiating insulin if there are no severe symptoms. However, patients with symptomatic hyperglycemia, unintended weight loss, or A1C >10% may require insulin initiation. Approximately one-third of adults with type 2 diabetes eventually require insulin as β-cell function declines. Basal insulin is typically the first choice, with prandial insulin added as needed for postprandial glucose control.
Use of diabetes technology is increasingly encouraged. Continuous glucose monitoring (CGM) was associated with a 0.31% A1C reduction and decreased time spent in hypoglycemia compared with blood glucose monitoring in randomized trials. Insulin pumps, in combination with CGM, were associated with additional A1C reductions and may benefit individuals on multiple daily injections.
The review supports a tailored, risk-based approach to care. Treatment decisions are now more closely aligned with each patient’s cardiovascular and renal risk, comorbidities, and treatment preferences. Broader complications—including diabetic retinopathy, nephropathy, and diabetes-associated conditions such as metabolic dysfunction–associated steatotic liver disease, cancer, and dementia—underscore the need for individualized therapy to reduce long-term morbidity and mortality.
Full disclosures are available in the published review.
Source: JAMA
