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Review
. 2025 Jan;68(1):17-28.
doi: 10.1007/s00125-024-06254-w. Epub 2024 Aug 19.

Glycaemic control is still central in the hierarchy of priorities in type 2 diabetes management

Kamlesh Khunti  1 , Francesco Zaccardi  2 , Aslam Amod  3 , Vanita R Aroda  4 , Pablo Aschner  5 , Stephen Colagiuri  6 , Viswanathan Mohan  7 , Juliana C N Chan  8
Affiliations
Review

Glycaemic control is still central in the hierarchy of priorities in type 2 diabetes management

Kamlesh Khunti et al. Diabetologia. 2025 Jan.

Abstract

A panel of primary care and diabetes specialists conducted focused literature searches on the current role of glycaemic control in the management of type 2 diabetes and revisited the evolution of evidence supporting the importance of early and intensive blood glucose control as a central strategy to reduce the risk of adverse long-term outcomes. The optimal approach to type 2 diabetes management has evolved over time as the evidence base has expanded from data from trials that established the role of optimising glycaemic control to recent data from cardiovascular outcomes trials (CVOTs) demonstrating organ-protective effects of newer glucose-lowering drugs (GLDs). The results from these CVOTs were derived mainly from people with type 2 diabetes and prior cardiovascular and kidney disease or multiple risk factors. In more recent years, earlier diagnosis in high-risk individuals has contributed to the large proportion of people with type 2 diabetes who do not have complications. In these individuals, a legacy effect of early and optimal control of blood glucose and cardiometabolic risk factors has been proven to reduce cardiovascular and kidney disease events and all-cause mortality. As there is a lack of RCTs investigating the potential synergistic effects of intensive glucose control and organ-protective effects of newer GLDs, this article re-evaluates the evolution of the scientific evidence and highlights the importance of integrating glycaemic control as a pivotal early therapeutic goal in most people with type 2 diabetes, while targeting existing cardiovascular and kidney disease. We also emphasise the importance of implementing multifactorial management using a multidisciplinary approach to facilitate regular review, patient empowerment and the possibility of tailoring interventions to account for the heterogeneity of type 2 diabetes.

Keywords: Cardiovascular outcomes; Glycaemic control; HbA1c; Legacy effect; Organ protection; Treatment paradigm; Type 2 diabetes.

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Conflict of interest statement

Acknowledgements: We would like to thank C. Rees (New Zealand), who provided medical writing support in the early stages of manuscript development on behalf of Springer Healthcare. Data availability: Data sharing is not applicable to this article as no datasets were generated or analysed during the current study. Funding: Medical writing support in the early stages of manuscript development, on behalf of Springer Healthcare, was funded by Servier. Authors’ relationships and activities: KK is supported by the National Institute for Health and Care Research (NIHR) Applied Research Collaboration East Midlands (ARC EM) and the NIHR Leicester Biomedical Research Centre (BRC) and has served as a consultant or speaker for, or received grants for investigator-initiated studies from AstraZeneca, Bayer, Novartis, Novo Nordisk, Sanofi-Aventis, Eli Lilly, MSD, Boehringer Ingelheim, Oramed Pharmaceuticals, Roche and Applied Therapeutics. FZ has received consulting fees from Daiichi Sankyo. VM has received research or educational grants from Abbott, Bayer, Boehringer Ingelheim, Eli Lilly, LifeScan, MSD, Novartis, Novo Nordisk, Sanofi-Aventis, Servier, USV, Dr. Reddy’s, Sun Pharma, Intas, Lupin, Glenmark, Zydus, Ipca, Torrent, Cipla, Biocon, Primus, Franco-Indian, Wockhardt, Emcure, Mankind, Medtronic, Fourrts, Apex, GSK and Alembic. PA has received honoraria or consulting fees from Boehringer Ingelheim, Janssen, MSD, Novartis and Sanofi and has participated in company-sponsored speakers bureaus for Eli Lilly, Boehringer Ingelheim, MSD, Novartis, Novo Nordisk and Sanofi. JCNC has received grants through her institutions and personal fees for consultancy and lectures from Astra Zeneca, Bayer, Boehringer Ingelheim, Hua Medicine, Eli Lilly, Merck, MSD, Powder Pharmaceuticals, Sanofi, Viatris and Zuellig Pharma outside the submitted work. SC has received an honorarium from Servier. The authors declare that there are no other relationships or activities that might bias, or be perceived to bias, their work. Contribution statement: KK and JC participated in the conception of the review and performed the literature searches. All authors were involved in the planning of the manuscript and read and contributed to writing all drafts of the manuscript. All authors approved the final version to be published.

Figures

Fig. 1
Fig. 1
Paradigms for managing type 2 diabetes and reducing diabetes-related complications based on (a) current consensus recommendations by the ADA/EASD [3] and (b) expert opinion of the authors
See this image and copyright information in PMC

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