The American Diabetes Association and the European Association for the Study of Diabetes have revised their joint guidelines, moving away from metformin as the default initial therapy for type 2 diabetes towards personalised treatment options including SGLT2 and GLP-1 therapies, emphasising broader health outcomes such as weight and organ protection.
The long-held assumption that metformin must come first in type 2 diabetes treatment is being challenged by the latest joint guidance from the American Diabetes Association and the European Association for the Study of Diabetes. According to the consensus report unveiled at EASD 2026 in Milan, treatment is moving away from a narrow focus on blood sugar towards a broader strategy that also targets weight, blood pressure, lipids and protection of the heart, kidneys and liver.
That shift matters because the new recommendations no longer treat metformin as an automatic starting point for everyone. Instead, the report says sodium-glucose co-transporter-2 inhibitors, or SGLT2 inhibitors, and glucagon-like peptide-1, or GLP-1, based therapies can be considered from diagnosis, regardless of HbA1c or prior metformin use. The organisations also describe SGLT2 inhibitors as the cornerstone for people with heart failure or chronic kidney disease, while GLP-1-based drugs are highlighted for reducing major cardiovascular events, supporting kidney protection and helping with weight loss.
The change reflects a wider reassessment of metformin’s role that has been building throughout 2026. Writing earlier this year, Diabetes in Control noted that the drug’s place as default first-line therapy was already under review as newer medicines showed benefits beyond glucose lowering, including fewer cardiovascular events, fewer hospital admissions for heart failure and slower progression of chronic kidney disease. In that context, the latest consensus does not discard metformin, but it does remove its status as a universal first step.
Weight management is another central theme in the new guidance. The ADA and EASD say treatments that reduce weight should be preferred where appropriate, and they also point to metabolic surgery as an option for selected patients. The report further discusses finerenone as an added layer of protection in albuminuric chronic kidney disease, while also addressing the use of semaglutide or tirzepatide in obesity-related heart failure with preserved ejection fraction, continuous glucose monitoring, reducing sulfonylureas in frail patients and improving access to treatment. A separate industry symposium at EASD 2026 underlined that metformin is still being discussed as part of early intervention strategies, but the centre of gravity in diabetes care appears to be moving decisively towards more personalised therapy choices.
Disclaimer: This content is for informational purposes only and is not intended to be a substitute for professional medical judgment, advice, diagnosis, or treatment.
