In 2020, the American Diabetes Association is making two paradigm-shifting recommendations in the treatment of type 2 diabetes.  

1. Prescribe Sodium glucose co-transporter 2 (SGLT2) inhibitors or glucagon-like peptide 1 (GLP-1) receptor agonists to patients at high risk for atherosclerotic cardiovascular disease, heart failure, or chronic kidney diseasein addition to patients with already established disease, as previously recommended.
2. Consideration for use of those drugs to be independent of the patients baseline A1c or individualized A1c target. Previously, additional pharmacologic agents were recommended only when A1c was above target despite using first-line metformin and lifestyle interventions. 

In case of Atherosclerotic CV Disease; add Empagliflozin

Heart Failure: Empagliflozin, canagliflozin or dapagliflozin. 

For heart failure patients with reduced ejection fraction (HFrEF) who have persistent symptoms and an elevated serum natriuretic peptide level on optimal pharmacologic and device therapy, add dapagliflozin.

CKD:  Canagliflozin in patients with diabetes and proteinuria. In patients with type 2 diabetes who have nephropathy (urine albumin excretion >300 mg per day) and eGFR >30 mL/min per 1.73 m², add Canagliflozin (CREDENCE trial).

In addition, SGLT2 inhibitors in general may have a role as a third agent in those who cannot or will not take insulin, when full doses of metformin and a sulfonylurea have not produced satisfactory metabolic control, or in patients in whom risk of hypoglycemia is high (frail, older adults) or in whom avoidance of weight gain is a priority.

Dr KK Aggarwal

Padma Shri Awardee

President Confederation of Medical Associations in Asia and Oceania (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA