Glycaemic control remains central in type 2 diabetes mellitus management: key learnings from the latest International Diabetes Federation guidelines

Abstract

The 2025 International Diabetes Federation (IDF) guidelines recognise global disparities in healthcare access, with ∼ 80% of people with type 2 diabetes mellitus (T2D) living in low-to-middle-income countries (LMICs). A panel of international experts discussed the evidence underlying these updated guidelines. Randomised trials demonstrate cardiovascular-kidney protection with sodium-glucose cotransporter 2 inhibitors (SGLT2is) and glucagon-like peptide-1 receptor agonists (GLP-1 RAs) in high-risk people with T2D, although their role among those with low-risk disease remains less clear. Whilst advocating for the need to improve access to newer glucose-lowering drugs (GLDs) in LMICs, the IDF guidelines propose two standards-of-care ('optimal' or 'basic'), with the following key messages: (i) early glycaemic control using conventional GLDs prevents complications and preserves quality of life; (ii) multifactorial management using effective GLDs and organ-protective drugs (e.g. statins and renin-angiotensin-aldosterone system inhibitors) improve outcomes; (iii) individualised regimens with shared decision-making and treatment persistence maximises benefits and minimises harm; (iv) metformin is a foundation therapy, with no evidence supporting first-line SGLT2i or GLP-1 RA monotherapy in low-risk individuals; (v) sulphonylureas are highly effective and affordable GLDs, making them important options (particularly in low-resource settings); and (vi) initial combination therapy achieves early glycaemic control with increased durability versus stepwise GLD addition.