New recommendations advise on adding SGLT-2 inhibitors and GLP-1 receptor agonists

A new guideline from The BMJ strongly recommends sodium-glucose cotransporter-2 (SGLT-2) inhibitors for patients with diabetes and established cardiovascular and chronic kidney disease, in addition to offering weaker support for starting glucagon-like peptide-1 (GLP-1) receptor agonists in this same patient population.


New rapid recommendations discuss when to add sodium-glucose cotransporter-2 (SGLT-2) inhibitors or glucagon-like peptide-1 (GLP-1) receptor agonists to treatment for type 2 diabetes.

The recommendations are part of the BMJ Rapid Recommendations series, a collaboration between the MAGIC group and The BMJ that brings together experts to develop recommendations based on recent evidence. The May 11 guideline bases drug selection on patients' individual risk of cardiovascular disease (CVD) and chronic kidney disease (CKD) as follows.

  • Three or fewer cardiovascular risk factors without CVD or CKD: Weak recommendation against starting SGLT-2 inhibitors or GLP-1 receptor agonists.
  • More than three cardiovascular risk factors without CVD or CKD: Weak recommendation for starting SGLT-2 inhibitors and weak recommendation against starting GLP-1 receptor agonists.
  • Established CVD or CKD: Weak recommendation for starting SGLT-2 inhibitors and GLP-1 receptor agonists.
  • Established CVD and CKD: Strong recommendation for starting SGLT-2 inhibitors and weak recommendation for starting GLP-1 receptor agonists.
  • For patients committed to further reducing their risk for CVD and CKD outcomes: Weak recommendation for starting SGLT-2 inhibitors rather than GLP-1 receptor agonists.

The authors noted that they systematically evaluated the balance of benefits, harms, other considerations, and practical issues for each risk group. A systematic review and network meta-analysis including 764 randomized trials of 421,346 patients found that SGLT-2 inhibitors and GLP-1 receptor agonists generally reduce overall death, myocardial infarctions, and end-stage kidney disease or kidney failure (moderate- to high-certainty evidence), the guideline noted. The benefit varied widely based on individual risk tiers ranging from five fewer deaths in the lowest-risk patients to 48 fewer deaths in the highest-risk groups.

“The strong recommendation for SGLT-2 inhibitors in patients with CVD and CKD reflects what the panel considered to be a clear benefit,” the guideline stated. “For all other adults with type 2 diabetes, the weak recommendations reflect what the panel considered to be a finer balance between benefits, harms, and burdens of treatment options.”