In recent years, glucagon-like peptide-1 receptor agonists (GLP-1 RAs) and sodium-glucose cotransporter-2 inhibitors (SGLT2s) have emerged as game changers in the management of type 2 diabetes management. These medications go beyond lowering blood glucose – they also help protect the heart and kidneys, and in some cases, promote weight loss. Yet, uptake is far from universal, with cost a major barrier. As these therapies become the gold standard in treatment guidelines, an important question looms: Can everyone afford them?
For many years, the primary focus in diabetes care was managing blood glucose levels. This glucose-centric approach aimed to prevent diabetes-related complications by keeping glucose levels close to normal. Numerous studies have demonstrated that early, intensive blood glucose management can reduce microvascular complications, such as those affecting the eyes (retinopathy), kidneys (nephropathy) and nerves (neuropathy).
Over time, however, treatment guidelines have evolved to prioritise cardiorenal outcomes. Cardiovascular outcome trials (CVOTs) have shown that SGLT2s reduce hospitalisations for heart failure and chronic kidney disease (CKD), while GLP-1 RAs reduce stroke and major adverse cardiovascular events (MACE). These results have helped shift the treatment toward a complications-centric approach that focuses on preventing life-threatening outcomes. However, it is important to note that, as CVOTs only include people at high risk, they do not apply to the majority (70-80%) of individuals with diabetes.
Speaking at the recent International Diabetes Federation World Diabetes Congress 2025 panel discussion on GLP-1 RAs and SGLT2s, Dr Roopa Mehta (Mexico) questioned whether this shift risks overlooking the foundational importance of blood glucose management. “Has the pendulum swung too far?” she asked. “Are we forgetting the critical importance of achieving early glycaemic control, especially in people without existing complications?”
For many years, the primary goal in diabetes care was managing blood glucose levels to prevent diabetes-related complications
Dr Mehta revisited data from the 1999 UK Prospective Diabetes Study (UKPDS), which showed thateach 1% reduction in HbA1c, results in a 37% decrease in microvascular complications and a 14% reduction in macrovascular complications. Importantly, there is no clear threshold – any improvement in HbA1c is beneficial.
This long-term benefit, often referred to as the “legacy effect”, demonstrates the value of taking early action. For example, a 50-year-old with an HbA1c of 8% who receives intensive early treatment can reduce their 20-year risk of death by 18%. Delaying treatment by 10 years lowers that benefit to just 6.6%.Multiple studies confirm that intensive management of numerous risk factors, including blood glucose, can extend life expectancy by approximately eight years. Real-world studies further support this: maintaining an HbA1c below 6.5% in the first year following a diabetes diagnosis is linked to a lower risk of complications in the long term.
End-stage renal disease and cardiovascular mortality remain high in low- and middle-income countries (LMICs). In Mexico, nearly 8 in 10 adults with type 2 diabetes are already living with complications by the time they are diagnosed, due to delayed detection and limited access to healthcare.
Early-onset type 2 diabetes – a growing global burden – presents additional challenges. Each decade earlier a person with diabetes is diagnosed , their life expectancy lowers by 3 to 4 years. A person diagnosed in their 30s may live a decade less than someone diagnosed at 50.
In these contexts, a complications-centric approach that starts with glucose management should take priority. Treatments using GLP-1 RAs and SGLT2s offer better health outcomes and protection against diabetes-related complications that can lead to premature death – but these benefits come at a price.
Findings from multiple studies indicate that intensive management of risk factors can extend life expectancy by approximately eight years
Despite their benefits, GLP-1 RAs and SGLT2s remain largely inaccessible for many people in LMICs. Their high cost, often several times that of older glucose-lowering therapies, presents a major barrier to widespread use, forcing health systems to make difficult decisions about resource allocation. As a result, even clinically effective treatments may be excluded from essential medicines lists or universal health coverage schemes if they fail to meet local cost-effectiveness thresholds.
Additional challenges – such as the need for specialist monitoring, storage infrastructure and consistent access – can limit their feasibility in primary care. Without mechanisms such as price negotiation, generic alternatives, or health technology assessments (HTAs) adapted to LMIC contexts, the benefits of these therapies may remain confined to high-income countries, exacerbating inequities in diabetes care.
Another panellist at the IDF 2025 session, Professor Juliana Chan (China), offered a broader perspective by comparing old and newer diabetes medications. While the benefits of GLP-1 RAs and SGLT2s are clear, older drugs such as metformin and sulfonylureas remain effective affordable and widely available. They still deliver the largest reductions in HbA1c, particularly when treatment begins early.
Diabetes is not a uniform condition. Rare forms of diabetes such as Maturity-Onset Diabetes of the Young (MODY) and Latent Autoimmune Diabetes in Adults (LADA) respond differently to treatments. This further complicates the picture and reinforces the need for personalised care.
For example, MODY responds well to sulfonylureas, while some LADA cases may benefit from DPP-4 inhibitors or basal insulin if residual beta-cell function remains. These variations mean that a blanket approach of putting everyone on a GLP-1 RAs or SGLT2s may be neither appropriate nor feasible.
Despite the known benefits, GLP-1 RAs and SGLT2s remain largely inaccessible for many people in LMICs
To address affordability, Dr Isaranuwatchai Wanrudee (Thailand) introduced Health Technology Assessment as a valuable decision-making tool. HTA evaluates interventions using a three-pronged framework: clinical effectiveness, economic evaluation (including cost-effectiveness and budget impact), and ethical/social implications. She stressed that HTA is not a tool for making decisions, but for supporting them.
In Thailand’s universal health coverage scheme, HTA has helped ensure equitable access to medications, vaccines, and other health technologies. ASEAN countries are also harmonising their HTA processes to reduce duplication and improve efficiency.
Dr Wanrudee also explained that cost-effectiveness is relative. What may be affordable in high-income countries may not be viable in LMICs. Yet, some low-cost treatments with high effectiveness are still included in Thailand’s universal health coverage, often following price negotiations or ethical considerations.
Even as we weigh the affordability of advanced therapies, foundational strategies, such as healthy lifestyles, timely diagnosis and education, remain cost-effective interventions with long-term impact.
The message was echoed by the panel moderator, Dr Ambady Ramachandran: “Treating diabetes may not be expensive. Treating it poorly, though, is definitely expensive.” Investing in effective, early, and persistent care pays dividends by reducing complications, mortality, and healthcare costs over time.
In Thailand’s universal health coverage scheme, HTA has helped ensure equitable access to medications, vaccines and other health technologies
If everyone were prescribed GLP-1 RAs and SGLT2s from diagnosis, would we see better outcomes? Possibly, but we lack direct evidence from trials in low-risk, newly diagnosed populations. More importantly, the financial implications of such a strategy would be considerable.Instead, a balanced, personalised strategy may offer the best path forward. Start by optimising blood glucose management using proven, affordable therapies. Add organ-protective agents when risk and resources allow. Use early combination therapy to prevent treatment delays and reduce the risk of future complications. Furthermore, always tailor treatment to the individual, recognising the heterogeneity of diabetes and the diversity of healthcare systems worldwide.
GLP-1 RAs and SGLT2s are powerful tools, not silver bullets. Their place on the frontline of diabetes care reflects important advances in understanding and technology. But frontline use must be accompanied by thoughtful deployment, equitable access, and economic sustainability.
Diabetes care today is about more than choosing between old and new, affordability or outcomes. It is about doing all of these – pragmatically, compassionately, and persistently.
