Current Guidelines and Recommendations

Based on this evidence, SGLT-2 inhibitors have carved an important role in the treatment of patients with T2DM and comorbid HF or CKD, as reflected in diabetes guidelines, which now prioritize SGLT-2 inhibitors as the agent of choice in this patients after first-line therapy with metformin or lifestyle modifications (Figure 26, American Diabetes Association 2020).  Furthermore, the new 2020 ADA guidelines now recommend SGLT-2 inhibitors even in T2DM patients that are at high-risk HF or CKD, but do not have established disease; a recommendation made independently of HbA1c levels (Figure 26, American Diabetes Association 2020).

Figure 26. 2020 American Diabetes Association T2DM Treatment Algorithm

The 2019 ACC/AHA guideline for the primary prevention of cardiovascular disease also makes a recommendation for the utilization of SGLT-2 inhibitors in patients with T2D and additional ASCVD risk factors in order to improve glycemic control and reduce cardiovascular risk (Table 2, Arnett 2019).

Table 2. Recommendations for adults with T2D, from the 2019 ACC/AHA primary CVD prevention guideline, COR = class of recommendation, LOE = level of evidence.
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