2023 Update: Luso-Brazilian evidence-based guideline for the management of antidiabetic therapy in type 2 diabetes

Marcello Casaccia Bertoluci, Wellington S Silva Júnior, Fernando Valente, Levimar Rocha Araujo, Ruy Lyra, João Jácome de Castro, João Filipe Raposo, Paulo Augusto Carvalho Miranda, Cesar Luiz Boguszewski, Alexandre Hohl, Rui Duarte, João Eduardo Nunes Salles, José Silva-Nunes, Jorge Dores, Miguel Melo, João Roberto de Sá, João Sérgio Neves, Rodrigo Oliveira Moreira, Marcus Vinícius Bolívar Malachias, Rodrigo Nunes LamounierDomingos Augusto Malerbi, Luis Eduardo Calliari, Luis Miguel Cardoso, Maria Raquel Carvalho, Hélder José Ferreira, Rita Nortadas, Fábio Rogério Trujilho, Cristiane Bauermann Leitão, José Augusto Rodrigues Simões, Mónica Isabel Natal Dos Reis, Pedro Melo, Mafalda Marcelino, Davide Carvalho

Research output: Contribution to journalReview articlepeer-review

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BACKGROUND: The management of antidiabetic therapy in people with type 2 diabetes (T2D) has evolved beyond glycemic control. In this context, Brazil and Portugal defined a joint panel of four leading diabetes societies to update the guideline published in 2020.

METHODS: The panelists searched MEDLINE (via PubMed) for the best evidence from clinical studies on treating T2D and its cardiorenal complications. The panel searched for evidence on antidiabetic therapy in people with T2D without cardiorenal disease and in patients with T2D and atherosclerotic cardiovascular disease (ASCVD), heart failure (HF), or diabetic kidney disease (DKD). The degree of recommendation and the level of evidence were determined using predefined criteria.

RESULTS AND CONCLUSIONS: All people with T2D need to have their cardiovascular (CV) risk status stratified and HbA1c, BMI, and eGFR assessed before defining therapy. An HbA1c target of less than 7% is adequate for most adults, and a more flexible target (up to 8%) should be considered in frail older people. Non-pharmacological approaches are recommended during all phases of treatment. In treatment naïve T2D individuals without cardiorenal complications, metformin is the agent of choice when HbA1c is 7.5% or below. When HbA1c is above 7.5% to 9%, starting with dual therapy is recommended, and triple therapy may be considered. When HbA1c is above 9%, starting with dual therapyt is recommended, and triple therapy should be considered. Antidiabetic drugs with proven CV benefit (AD1) are recommended to reduce CV events if the patient is at high or very high CV risk, and antidiabetic agents with proven efficacy in weight reduction should be considered when obesity is present. If HbA1c remains above target, intensification is recommended with triple, quadruple therapy, or even insulin-based therapy. In people with T2D and established ASCVD, AD1 agents (SGLT2 inhibitors or GLP-1 RA with proven CV benefit) are initially recommended to reduce CV outcomes, and metformin or a second AD1 may be necessary to improve glycemic control if HbA1c is above the target. In T2D with HF, SGLT2 inhibitors are recommended to reduce HF hospitalizations and mortality and to improve HbA1c. In patients with DKD, SGLT2 inhibitors in combination with metformin are recommended when eGFR is above 30 mL/min/1.73 m2. SGLT2 inhibitors can be continued until end-stage kidney disease.

Original languageEnglish
Article number160
JournalDiabetology and Metabolic Syndrome
Issue number1
Publication statusPublished - 19 Jul 2023


  • Atherosclerotic disease
  • Cardiovascular risk
  • Chronic kidney disease
  • DKD
  • Diabetes treatment
  • GLP-1 RA
  • Guidelines
  • Heart failure
  • Ischemic heart disease
  • SGLT2 inhibitors
  • pe 2 diabetes


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