Dr. Ahmed Farhan
Big news landed for people with type 2 diabetes this week. On October 2, 2026, two of the world’s most trusted diabetes groups released new treatment advice. It is the first big update since 2022.
Around the same time, researchers in Sweden shared results from a large trial. It compared metformin, the medicine most people start with, to a newer kind of medicine. Many people now ask one simple question: is metformin still the first choice?
The honest answer is “it depends.” The new advice is also more careful than some headlines make it sound.
Let’s walk through what changed, what the trial found, and what nobody knows yet. This article is for learning only. It is not medical advice. No one should change a medicine without talking to their own health care team first.
Why This Topic Is Trending Now
Every fall, thousands of diabetes experts meet in Europe to share new research. This year the meeting was in Milan, Italy, from September 28 to October 2. More than 16,000 people took part.
The last day was the big one. That is when the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) published their joint advice in two medical journals, Diabetes Care and Diabetologia. These two groups have teamed up on this advice since 2006. The last update came in 2022.
A rough draft was shown in June at the ADA’s yearly meeting. At that time, one of the leaders warned that the draft could still change after expert review. Now the final version is out, so people are talking.
What the Latest Research Says
Part 1: The new guidelines
A guideline is not a single study. It is a group of experts reading lots of research and agreeing on advice.
Think of it like a coach’s playbook built from many games. Here are the main changes, based on the ADA’s announcement and the report itself.
- Earlier action. The experts want medicines used early in the course of the disease, even from the time of diagnosis, to prevent problems later.
- Two medicine groups move up. SGLT2 inhibitors and GLP-1-based medicines are now advised for earlier use. SGLT2 inhibitors work by helping your body get rid of extra sugar through your urine. GLP-1-based medicines act like a natural gut hormone that helps with blood sugar and appetite.
- Protection beyond blood sugar. The goal is bigger than a lab number. It now includes protecting the heart, kidneys, and liver, and reaching a healthy weight.
- A plan that fits you. The ADA says treatment should be matched to a person’s own heart and kidney risk.
- More checking for related problems. These include heart failure, fatty liver disease, sleep apnea, anxiety and depression, and gum health.
- A 24-hour habit plan. The report lays out healthy habits for a whole day, from moving to sleeping.
One point matters a lot for the metformin question. The report says the heart and kidney benefits of these two medicine groups do not depend on whether a person also takes metformin.
Early coverage before the meeting said the advice would ask doctors to “consider” these medicines as a first step, with or without metformin.
The word “consider” is important. It is not an order to stop metformin. It is an invitation to look at each person’s health picture and choose what fits.
Part 2: The SMARTEST trial
The second piece of news is a trial named SMARTEST. It was run by Uppsala University in Sweden. The team asked a direct question: for people with early type 2 diabetes, is a newer medicine (dapagliflozin, an SGLT2 inhibitor) a better starting point than metformin?
The study followed 2,072 people. They were signed up at about 40 local centers, mostly regular health clinics. Each person was picked by chance to take either metformin or dapagliflozin by itself. Then they were followed during normal care, the way real life works, instead of in a lab-like setting.
What the Researchers Actually Found
The SMARTEST results were shared at the Milan meeting. According to a report from a Swedish diabetes news outlet, people were followed for about 3.8 years.
The main question was whether one medicine did better at preventing death, major heart problems, and damage to small blood vessels (which can harm the eyes, kidneys, and nerves).
The answer: no clear difference. The report said there was no statistical difference between the two medicines on that main measure. Both medicines were also described as safe and well tolerated.
There were two interesting details. First, fewer people died or had major heart problems than the researchers expected.
Second, more people than expected developed new small-blood-vessel problems. The reporter said the high quality of Swedish primary care may have made differences harder to see. When everyone gets good care for blood pressure, cholesterol, and more, it is harder for one medicine to stand out.
There is also a smaller study from 2026. It had only 60 people who had just been diagnosed. They took metformin, dapagliflozin, or both for 12 weeks.
The main measure, how well blood vessels work, did not differ between groups. One side measure, the thickness of the artery wall, improved more with dapagliflozin. The authors themselves called these results a starting point that needs bigger studies.
Evidence check: The new guidelines are expert opinion built on years of trial evidence, so they carry real weight. The SMARTEST results are emerging evidence. I could only find them described at a conference and in a news report, not yet in a full published paper. The 60-person study is a hypothesis-generating study, which means it suggests ideas but cannot settle them.
What It Means for Diabetes and Metabolic Health
For many years, diabetes care focused on one thing: bringing blood sugar down. That still matters. But think of a car. Watching only the gas gauge is not enough. You also care about the engine, the brakes, and the tires.
The new advice treats type 2 diabetes the same way. It is a condition that can slowly affect the heart, kidneys, liver, nerves, and eyes. So the plan now aims to protect all of them, not only to lower one number.
Weight is part of this too. A summary of the report says that losing 10 to 15 percent of body weight or more, early in the disease, makes it more likely that blood sugar returns to the normal range. That summary comes from a medical news site, so check the full report for exact wording.
The same summary says that, with GLP-1-based medicines, roughly a quarter to two-fifths of the weight lost can be muscle. That is why the guidance stresses strength training and enough protein. Muscle helps your body handle sugar, so keeping it is a big deal.
Practical Implications: The “Five S” Daily Habits
Medicines are only one part of the new advice. The report also builds on a simple 24-hour plan called the Five S’s. It first appeared in the 2022 version, and it is easy to remember.
- Sitting less. Break up long stretches of sitting with a few minutes of light movement.
- Stepping. Add more steps to your day. A summary of the 2026 report lists a range of 6,000 to 10,000 steps a day for health benefits.
- Sweating. Aim for about 150 minutes a week of moderate to hard activity, like brisk walking, if your doctor says it is safe for you.
- Strengthening. Work your muscles two to three times a week. Body-weight moves and weights both count.
- Sleep. Good sleep helps your body manage sugar. The same summary lists 7 to 8 hours with regular timing.
None of these needs a gym or fancy gear. Small changes add up, and they work alongside any medicine.
What We Know
- Two major diabetes groups now advise thinking about SGLT2 inhibitors and GLP-1-based medicines earlier, with a focus on protecting the heart, kidneys, and liver.
- The report says the heart and kidney benefits of these medicines do not depend on metformin.
- In a large Swedish trial, metformin and dapagliflozin did not show a clear difference on the main outcome after about 3.8 years, according to a news report of the results.
- Healthy daily habits, such as moving more, strengthening muscles, and sleeping well, remain part of the advice no matter which medicine someone uses.
What We Don’t Know
- We do not yet have the full published SMARTEST paper, so details like exact numbers and side effects are not available to me.
- We do not know if one starting plan is better for every person. The guideline says to tailor care, which tells us the answer likely differs from person to person.
- We do not know how costs and insurance coverage will change. Newer medicines can cost more, and access varies by place.
- We do not know the very long-term results of starting these medicines at the moment of diagnosis.
Common Misconceptions
Myth: “Metformin is now outdated.” Not so. The guidance says doctors should consider newer medicines first, with or without metformin. It does not say metformin has stopped working or should be dropped. In SMARTEST, metformin did about as well as the newer medicine on the main outcome.
Myth: “The new medicines are better for everyone.” The guideline stresses matching treatment to your own heart and kidney risk. A person with higher risk may be advised differently than a person with lower risk.
Myth: “If I take a medicine, habits don’t matter.” The same report that moves medicines up also puts a 24-hour habit plan front and center. Medicine and lifestyle are meant to work as a team.
Myth: “A guideline is a rule for my body.” A guideline is advice for doctors about groups of people. Your own doctor knows your history, other medicines, and goals.
Who Should Pay Particular Attention
Anyone recently diagnosed with type 2 diabetes can use this news to start a better conversation with their care team. So can people who have lived with it for years and wonder whether their plan is up to date.
The guidance puts extra focus on people who also have heart disease, long-term kidney disease, or heart failure. It also points out that people diagnosed at a young age may face faster damage and may need closer attention.
Every medicine can have side effects. For SGLT2 inhibitors, medical references list yeast infections in the genital area, more frequent urination, dehydration, and, rarely, a serious problem called ketoacidosis. GLP-1-based medicines can cause nausea, vomiting, or diarrhea, especially at the start. These are good reasons to talk to your own doctor or pharmacist instead of deciding alone.
The guidance also gives more attention to mental health. Separately, the EASD has published its first-ever guideline on diabetes distress, which is the heavy emotional strain that can come with managing diabetes every day. If that sounds familiar, tell your care team. It is a real part of diabetes care.
Practical, Evidence-Based Recommendations
These ideas are for general learning. They do not replace advice from your doctor.
- Bring the news to your next visit. Ask, “Does the 2026 advice change anything for me?” That question invites a plan built for you.
- Keep taking your medicines as prescribed. Do not stop or switch because of a headline. If you have a concern, call your doctor or pharmacist.
- Ask about your whole-body risk. Questions about your heart, kidneys, liver, sleep, and mood are all fair game now.
- Pick one “S” to improve this week. Try a short walk after a meal, a set of body-weight exercises, or a steadier bedtime.
- Prepare your questions. Write down what you want to ask about cost and side effects before your visit so you do not forget.
Frequently Asked Questions
Is metformin still used for type 2 diabetes?
Yes. The new guidance does not say to drop it. It says doctors should consider newer medicines early, with or without metformin, based on each person’s health. In the SMARTEST trial, metformin and the newer medicine did not show a clear difference on the main outcome.
Does this mean I should switch my medicine?
Not on your own. Guidelines are advice for doctors about groups of people. Only your health care team knows your history and goals. Use the news as a reason to ask questions, not to change your treatment.
What are SGLT2 inhibitors and GLP-1-based medicines?
They are two groups of diabetes medicines. SGLT2 inhibitors help the body remove extra sugar in the urine. GLP-1-based medicines act like a gut hormone that helps with blood sugar and appetite. The new guidance says both groups can help protect the heart and kidneys.
Do these medicines have side effects?
Yes, like all medicines. SGLT2 inhibitors can cause genital yeast infections, more urination, and dehydration, and rarely ketoacidosis. GLP-1-based medicines can cause stomach upset. Your doctor or pharmacist can explain what to watch for.
Do habits like walking and sleep still matter if I take medicine?
Yes. The 2026 report keeps a 24-hour plan for sitting less, stepping, sweating, strengthening, and sleeping. These habits work alongside medicine.
When will the full SMARTEST results be published?
I could not find a publication date. So far, the results have been shared at a conference and described in a news report. Watch for the full paper to see the details.
Conclusion
The 2026 guidelines mark a shift. Type 2 diabetes care is moving from “lower the blood sugar number” to “protect the whole body, early.”
That is why two medicine groups moved up the list and why habits like strength training and sleep now share the spotlight.
But the metformin story is not a simple “old versus new.” Metformin is still a trusted option, and the largest trial on the question found no clear winner on the main outcome. The best choice may depend on your heart, your kidneys, your weight, your budget, and your goals.
If you have type 2 diabetes, the best next step is simple. Take this article to your next appointment and ask what the new advice means for you.
References
- American Diabetes Association. Leading Diabetes Organizations Publish Joint Consensus Report on the Management of Type 2 Diabetes. Press release, October 2, 2026. [Link]
- Davies MJ, Aroda VR, Bajaj M, et al. Management of type 2 diabetes, 2026. A consensus report by the ADA and the EASD. Diabetologia. 2026. [Link](also published in Diabetes Care, https://doi.org/10.2337/dci26-0141).
- Medscape. EASD 2026 to Feature New Diabetes Approaches. September 24, 2026. [Link]
- Dagens Diabetes. EASD Report. SMARTEST. Metformin SGLT2i. No difference. October 2026 (in Swedish). [Link]
- Uppsala University. SMARTEST study page (design, 2,072 participants, about 40 centers). [Link]
- Sundström J, et al. SMARTEST design and endpoint-capture paper. Scandinavian Cardiovascular/Diabetes and Vascular Disease Research, 2023. [Link]
- Chee et al. First-line dapagliflozin, metformin, or combination therapy in type 2 diabetes: vascular and molecular outcomes of a randomised controlled trial. Diabetes, Obesity and Metabolism. 2026. [Link]
- Medical Dialogues. ADA-EASD 2026 Consensus Guidelines: 6 key updates. October 5, 2026 (secondary summary; used for the Five S details, weight-loss and muscle-loss figures). [Link]
- American Diabetes Association. Draft ADA/EASD consensus slides, ADA Scientific Sessions, June 2026. [Link]
- Pharmacy Times. ADA 2026: Earlier GLP-1 and SGLT-2 Use Recommended From Diabetes Diagnosis, Expert Says. 2026. [Link]
- Diabetes on the Net. ADA/EASD Consensus Report update 2022: What’s new? (Origin of the Five S’s). [Link]
- Clinical Medicine. Adverse reactions to SGLT2 inhibitors (Table 4). 2021;21(3):204–210. [Link]
- Endocrine Practice. Mitigation of side effects for newer agents (Table 12), AACE guideline. 2022. [Link]
This article is for general education and is not medical advice. Talk to your own health care team before starting, stopping, or changing any medicine.
