American Diabetes Association · Standards of Care · January 2026
A comprehensive visual guide to the ADA 2026 evidence-based recommendations for glucagon-like peptide-1 receptor agonist therapy in type 2 diabetes and obesity management
GLP-1 receptor agonists mimic endogenous incretins to achieve pleiotropic metabolic benefits through multiple pathways.
Glucose-dependent insulin secretion — lowers risk of hypoglycaemia. Stimulates insulin synthesis and β-cell proliferation.
Reduces appetite and food intake via central GLP-1R signalling. Promotes satiety, decreases hedonic eating.
Reduces MACE, atherosclerosis progression, inflammation and oxidative stress. Improves endothelial function.
Reduces albuminuria and slows CKD progression. New 2026: initiation/continuation on dialysis to reduce CV risk.
Slows gastric emptying — blunts post-prandial glucose excursions. Reduces glucagon secretion from α-cells.
NEW 2026: GLP-1 RA with proven MASH benefit preferred in T2D + biopsy-proven MASH or high fibrosis risk.
Suppresses glucagon secretion in a glucose-dependent manner. Reduces fasting and post-prandial hyperglucagonaemia.
Emerging 2026 evidence: GLP-1 RA may slow cognitive decline in older adults with T2D (diabetes-related dementia).
Each recommendation is graded by level of evidence. Grade A = clear evidence from well-conducted RCTs or meta-analyses.
In adults with T2D and established or high risk of ASCVD, include a GLP-1 RA and/or SGLT2i in the treatment plan for glycaemic management AND comprehensive CV risk reduction — irrespective of A1C level.
In T2D with overweight/obesity, the preferred pharmacotherapy is a GLP-1 RA or dual GIP/GLP-1 RA with greater weight loss efficacy (i.e., semaglutide or tirzepatide), especially considering their weight-independent benefits.
In T2D with biopsy-proven MASH or high risk for liver fibrosis (noninvasive tests), a GLP-1 RA is preferred for glycaemic management due to beneficial effects on MASH histology.
In T2D + MASLD + overweight/obesity, consider a GLP-1 RA with demonstrated MASH benefit, or dual GIP/GLP-1 RA with potential MASH benefit, as adjunctive therapy to lifestyle intervention.
Consider combination therapy in adults with T2D for initial treatment to shorten time to attainment of individualised glycaemic goals. GLP-1 RA + metformin is a robust initial combination.
Use medications providing sufficient effectiveness to achieve treatment goals, with consideration of CV/kidney/weight effects, hypoglycaemia risk, cost and access, adverse reactions/tolerability, and individual preferences.
New 2026: Guidance added for initiation or continuation of GLP-1–based therapy in individuals on dialysis to reduce cardiovascular risk. Previously, dialysis patients were excluded from this guidance.
New 2026: GLP-1 receptor agonists and metabolic surgery are now recommended as adjunctive therapies in T1D with obesity, alongside insulin management.
GLP-1 or dual GIP/GLP-1 receptor agonists supported when evidence shows benefit. Recommendations specifically address symptomatic HF management with GLP-1 RA consideration.
Updated 2026: Discontinue GLP-1 RA and dual GIP/GLP-1 therapy before attempting conception. These agents are not recommended during pregnancy due to insufficient safety data.
Combination therapy with pioglitazone + GLP-1 RA can be considered for hyperglycaemia in T2D with biopsy-proven MASH or high fibrosis risk due to potential beneficial effects on MASH.
New emphasis 2026: Obesity pharmacotherapy recommendations stress individualised dosing and titration to optimise efficacy, minimise adverse effects, and enhance medication adherence.
ADA 2026 person-centred framework for initiating and optimising GLP-1 RA therapy in T2D
GLP-1 RA +/or SGLT2i
Irrespective of A1C
Preferred: semaglutide, liraglutide, dulaglutide
Semaglutide 2.4mg SC or Tirzepatide
Max dose for max efficacy
Individualised titration 2026
GLP-1 RA + SGLT2i
Continue even on dialysis
New 2026: dialysis inclusion
Oral semaglutide 3–14mg OD
Taken 30 min before first meal
Moderate A1C reduction
Semaglutide SC 0.5–2mg
Dulaglutide 0.75–4.5mg
Tirzepatide 2.5–15mg
Liraglutide 0.6–1.8mg OD
Exenatide 5–10mcg BD
MASH: liraglutide/semaglutide
Continue current regimen · Annual review · CGM if appropriate · Reinforce lifestyle
ContinueIntensify dose to maximum tolerated · Add SGLT2i if not already · Address adherence
IntensifySwitch agent within class · Consider tirzepatide · Refer for bariatric surgery if BMI criteria
Switch / EscalateComparison of licensed agents relevant to ADA 2026 recommendations. *UK NHS availability may differ — refer to local formulary and NICE guidance.
| Agent | Class | Route / Frequency | A1C Reduction | Weight Loss | CV Outcome Trial | MASH Benefit | ADA 2026 Role |
|---|---|---|---|---|---|---|---|
Semaglutide SC Ozempic® / Wegovy® |
GLP-1 RA | SC weekly | 1.5–2.0% | 5–15% (DM); up to 15% (Wegovy) | SUSTAIN-6 / SELECT (+20% MACE ↓) | Yes — NASH studies positive | Preferred — CV & Obesity |
Tirzepatide Mounjaro® / Zepbound® |
Dual GIP/GLP-1 RA | SC weekly | 2.0–2.5% | 15–22% (SURMOUNT-1) | SURPASS-CVOT (pending full data) | Potential — MASH studies ongoing | Preferred — Max Weight Loss |
Oral Semaglutide Rybelsus® |
GLP-1 RA | Oral daily | 1.0–1.4% | 2–4% | PIONEER-6 (non-inferior) | Limited data | Consider — Injection-averse |
Liraglutide Victoza® / Saxenda® |
GLP-1 RA | SC daily | 1.0–1.5% | 3–8% | LEADER (13% MACE ↓) | Yes — LEAN trial (NASH benefit) | Consider — Proven CV + MASH |
Dulaglutide Trulicity® |
GLP-1 RA | SC weekly | 1.0–1.6% | 2–4% | REWIND (12% MACE ↓) | Limited data | Consider — Weekly, auto-inject device |
Exenatide QW Bydureon BCise® |
GLP-1 RA | SC weekly | 0.9–1.3% | 2–3% | EXSCEL (neutral) | Not established | Alternative |
Exenatide BD Byetta® |
GLP-1 RA | SC twice daily | 0.8–1.1% | 1–3% | No CV outcome trial | Not established | Less preferred |
† Refer to manufacturer's prescribing information for full dosing. Data summarised from major CVOTs and clinical trials. ADA 2026 does not endorse specific brands.
Visual representation of key trial outcomes supporting ADA 2026 recommendations for GLP-1 RA use.
ADA 2026 comorbidity-guided guidance — matching the right therapy to the right patient profile.
GLP-1 RA with proven MACE reduction (semaglutide, liraglutide, dulaglutide) should be included irrespective of A1C. May combine with SGLT2i for additive benefit.
Preferred · Grade AGLP-1 or dual GIP/GLP-1 RA supported when evidence shows benefit for symptomatic HF. SGLT2i has strongest evidence for HFrEF. Consider combination. Monitor volume status.
Consider · Grade BContinue or initiate GLP-1 RA even with advanced CKD. New 2026: Can initiate or continue on dialysis for CV risk reduction. Check agent-specific eGFR thresholds.
New 2026 · Grade AGLP-1 RA preferred in T2D + biopsy-proven MASH. Consider pioglitazone + GLP-1 RA combination. Refer to hepatologist if FIB-4 >2.67.
New 2026 Update · Grade ASemaglutide 2.4mg or tirzepatide preferred for maximum weight loss efficacy. Individualised dosing and titration now emphasised. Consider bariatric surgery if BMI ≥35 with complications.
Preferred · Grade AGLP-1 RA and SGLT2i show small benefits slowing cognitive decline in T2D. New entity: 'diabetes-related dementia'. Simplified regimens preferred in frail elderly. Low hypoglycaemia risk advantageous.
Emerging EvidenceDiscontinue GLP-1 RA before attempting conception. Not recommended during pregnancy — insufficient safety data. Switch to insulin-based regimen when planning pregnancy.
Discontinue · Grade ENew 2026: GLP-1 RA now recognised as adjunctive therapy in T1D with obesity, alongside insulin. Also: metabolic surgery considered in eligible T1D + obesity patients.
New 2026 · Grade BNew 2026: Comprehensive guidance on glycaemic management during cancer therapy including mTOR inhibitors, PI3K inhibitors, immune checkpoint inhibitors and glucocorticoids.
New 2026 SectionAdding GLP-1 RA to insulin regimen reduces hypoglycaemia risk vs basal-bolus insulin. May allow insulin dose reduction. Weekly GLP-1 RA preferred for adherence.
Grade A2026 Statement: ADA recommends against non-FDA-approved compounded GLP-1 and dual GIP/GLP-1 products due to uncertain content, safety, quality and effectiveness.
Avoid Compounded · ADA 2026Consider combination therapy from diagnosis to shorten time to glycaemic goals. GLP-1 RA + metformin well-validated. A1C-guided but comorbidity-informed choice throughout.
Consider · Grade AUnderstanding the safety profile of GLP-1 RAs is essential for person-centred prescribing decisions.
ADA guidelines are internationally recognised and increasingly aligned with UK practice. The DiabetesontheNet 2026 At-A-Glance noted that "most recommendations are relevant to healthcare professionals in the UK." Key UK considerations:
Most significant new or updated GLP-1 RA-relevant recommendations versus ADA 2025.
First formal ADA recommendation endorsing GLP-1 RA as adjunct therapy in T1D patients with obesity, alongside insulin.
New recommendation allowing initiation or continuation of GLP-1–based therapy in CKD patients on dialysis for CV risk reduction.
Rec 4.26 and 4.27a updated — GLP-1 RA with demonstrated MASH benefit now explicitly preferred in T2D + biopsy-proven MASH or high fibrosis risk.
New 2026 emphasis on individualised titration to optimise efficacy, minimise AEs, and enhance adherence — especially semaglutide and tirzepatide.
Updated guidance explicitly states GLP-1 RA and dual GIP/GLP-1 should be discontinued before attempting conception.
2026 introduces comprehensive glycaemic management guidance for patients on cancer therapies (immune checkpoint inhibitors, mTOR/PI3K inhibitors).
Updated clinical algorithm for symptomatic HF management now specifically addresses GLP-1 or dual GIP/GLP-1 RA when evidence supports benefit.
New ADA guidance statement formally recommending against non-FDA-approved compounded GLP-1 and dual GIP/GLP-1 products.
2026 emphasis: individualised titration is key. Slow up-titration reduces GI adverse effects and improves adherence.
T2D: Start 0.25mg → 0.5mg (4 weeks) → 1mg (4 weeks) → 2mg if needed
Obesity (Wegovy®): Start 0.25mg → titrate over 16 weeks to 2.4mg weekly
Inject SC abdomen, thigh or upper arm.
Start: 2.5mg → 5mg (4 weeks) → 7.5mg → 10mg → 12.5mg → 15mg
Titrate every 4 weeks as tolerated. Maximum 15mg weekly.
Individualized dose target per ADA 2026 — not all need 15mg.
Start: 0.6mg OD × 1 week → 1.2mg OD → 1.8mg OD if needed
Administer any time, independent of meals.
Preferred in MASH — LEAN trial evidence.
Start: 3mg OD × 4 weeks → 7mg OD × 4 weeks → 14mg OD
Take on an empty stomach, ≥30 min before food/drink/other medication, with max 120mL water. Swallow whole.
Start: 0.75mg weekly → 1.5mg weekly
Can increase to 3mg → 4.5mg for additional glycaemic control.
Single-use auto-injector device — no reconstitution required.
Fixed dose: 2mg SC once weekly. No titration required.
Inject abdomen, thigh or upper arm. Can inject any time, with or without food.
May see injection site nodule — normal with microspheres.
A1C every 3 months until stable, then every 6 months. CGM preferred where available and clinically indicated. Target A1C individualised (typically <53mmol/mol / <7% in most adults).
Monthly weight review initially. Target ≥5% body weight loss at 16 weeks as indicator of response. If <5% at max tolerated dose, reassess and consider switching or escalating.
eGFR and ACR at least annually. Monitor for eGFR decline when adding medications. GLP-1 RA can continue in most stages of CKD — check agent-specific SPC for thresholds.
FIB-4 calculation at baseline and annually. If FIB-4 >2.67 — refer hepatology. Liver function tests + fibroscan where indicated. GLP-1 RA response in MASH: reassess histology at 1 year if biopsy-proven.
Blood pressure, lipid profile, resting ECG where indicated. Monitor heart rate. ASCVD risk score annually (QRISK3 in UK). Optimise all CV risk factors concurrently.
Review concomitant insulin/SU doses when initiating GLP-1 RA — reduce to prevent hypoglycaemia. Check drug interactions (especially narrow TI oral medications). Annual medication reconciliation.