ADA 2026 Standards Expand GLP-1 Use, Lower BP Target for High-Risk Patients

ADA 2026 Standards of Care recommend a systolic blood pressure goal below 120 mmHg in high-risk patients, broaden GLP-1 receptor agonist use across cardiometabolic conditions, and add new MASH guidance for internists managing type 2 diabetes.

April 25, 2026 · 4 min read

The Story at a Glance:

ADA 2026 Standards of Care lower the systolic blood pressure goal to below 120 mmHg in adults with diabetes who have high cardiovascular or kidney risk
A GLP-1 receptor agonist with demonstrated benefit is now preferred for type 2 diabetes plus biopsy-proven MASH or high risk of liver fibrosis
Dual GIP/GLP-1 receptor agonists join the medications recommended for heart failure with preserved ejection fraction (HFpEF)
The full guidance was released December 8, 2025, and published in the January 2026 Diabetes Care supplement

What Happened

The ADA 2026 Standards of Care, released by the American Diabetes Association on December 8, 2025, update recommendations across cardiovascular, kidney, hepatic, and obesity care for adults with diabetes. The full document appears in the January 2026 supplement of Diabetes Care and reflects the annual revision developed by the ADA’s Professional Practice Committee.

Three changes are particularly relevant to internal medicine. Recommendation 10.4 now encourages a systolic blood pressure (SBP) goal below 120 mmHg in adults with diabetes who have high cardiovascular or kidney risk, when the target can be safely achieved. Recommendation 4.27a designates a GLP-1 receptor agonist (GLP-1 RA) with demonstrated benefit as the preferred glucose-lowering agent in patients with type 2 diabetes plus biopsy-proven metabolic dysfunction-associated steatohepatitis (MASH) or high risk of liver fibrosis.

A new Recommendation 9.9a supports a dual GIP and GLP-1 RA with proven benefit for heart-failure symptoms and event reduction, while Recommendation 11.11a addresses GLP-1 therapy continuation or initiation in patients on dialysis.

Why the ADA 2026 Standards Matter for Internal Medicine

For internists who deliver most diabetes care in the United States, the ADA 2026 Standards reframe several routine decisions. The lower SBP goal raises the intensity of antihypertensive therapy in patients with established atherosclerotic disease or chronic kidney disease (CKD).

The MASH guidance asks clinicians to integrate hepatic risk into glucose-lowering choice, particularly when the fibrosis-4 (FIB-4) index is elevated. Patients with FIB-4 above 2.67 should be referred to a liver specialist.

GLP-1 RA expansion across CKD on dialysis, asymptomatic stage B heart failure, and HFpEF blurs the line between glycemic control and cardiorenal protection — extending a treatment-by-comorbidity approach to a broader population.

Key Numbers Behind the ADA 2026 Standards

The new SBP target rests primarily on two large randomized trials in adults with diabetes or elevated cardiovascular risk.

BPROAD trial: in adults with diabetes and elevated cardiovascular risk, an intensive SBP goal of below 120 mmHg versus below 140 mmHg cut a composite of nonfatal stroke, nonfatal myocardial infarction (MI), heart failure, or cardiovascular death by 21%
ESPRIT trial: intensive treatment to below 120 mmHg versus below 140 mmHg reduced a composite of MI, revascularization, heart-failure hospitalization, stroke, atrial fibrillation, or cardiovascular death by 12% (3.5% vs 4.6%; HR 0.74, 95% CI 0.60–0.92)
Hypotension occurred in 3.4% of the intensive group versus 2.6% of the standard group in ESPRIT, with no significant difference in syncope or fractures
Weight loss target was strengthened to 5–7% of baseline body weight to improve glycemia and cardiometabolic risk factors

What Experts Are Saying

“Significant advancement in the delivery of evidence-based, person-centered care.” — Rita Kalyani, MD, MHS, Chief Scientific and Medical Officer, American Diabetes Association

Robert Gabbay, MD, PhD, of the Joslin Diabetes Center in Boston, has highlighted that the headline change is the stronger push toward a 120 mmHg systolic target in patients with renal or cardiovascular risk when it can be achieved safely. Gabbay also points to the lower LDL-cholesterol goals introduced in earlier Standards — below 55 mg/dL for diabetes plus atherosclerotic cardiovascular disease and below 70 mg/dL for high-risk patients — as decisions that still warrant attention in primary care.

What’s Next

The ADA’s Primary Care Advisory Group plans to publish an abridged version of the Standards in spring 2026 in Diabetes, Obesity, and Cardiometabolic CARE. As a “living guideline,” the online version will update in real time when new trial data or regulatory decisions warrant.

Internists should expect coverage decisions from CMS and major payers to evolve over coming months, particularly around GLP-1 RA expansion to dialysis and HFpEF populations.

Bottom Line

Identify candidates for the new ADA 2026 Standards SBP target below 120 mmHg — adults with diabetes plus established ASCVD, multiple risk factors, or CKD — and titrate antihypertensive therapy carefully to avoid hypotension and acute kidney injury
Screen for hepatic fibrosis using FIB-4 in patients with type 2 diabetes; consider a GLP-1 RA with MASH evidence when fibrosis risk is elevated and refer those with FIB-4 above 2.67 to hepatology
Reconsider glucose-lowering choice in patients on dialysis, with HFpEF, or with stage B heart failure — GLP-1 RAs and dual GIP/GLP-1 RAs now have specific recommendations
Counsel patients on a 5–7% weight-loss target as part of cardiometabolic risk reduction, individualizing antiobesity drug dosing to balance tolerability, efficacy, and benefit

Sources

American Diabetes Association. The American Diabetes Association Releases “Standards of Care in Diabetes—2026.” ADA Newsroom, December 8, 2025. ADA Press Release — Standards of Care in Diabetes 2026
American Diabetes Association Professional Practice Committee. Summary of Revisions: Standards of Care in Diabetes—2026. Diabetes Care, January 2026; 49 (Suppl 1): S6–S12. Diabetes Care — Summary of Revisions 2026
American Diabetes Association Professional Practice Committee. 10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes—2026. Diabetes Care, January 2026; 49 (Suppl 1): S216–S249. Diabetes Care — Section 10, Cardiovascular Disease and Risk Management
touchCARDIO. ADA 2026 Standards of Care: What the update means for cardiovascular clinical practice — Q&A with Robert Gabbay, MD, PhD. February 6, 2026. touchCARDIO — Q&A on ADA 2026 Standards with Dr Robert Gabbay
Patient Care Online. ADA Publishes 2026 Standards of Care With Updates to Sections on Technology, Obesity, Cardiometabolic Disease Management. December 2025. Patient Care Online — ADA 2026 Standards Coverage
Cardi-OH. Key Updates from the 2026 ADA Standards of Care. Current Issue 59, February 2026. Cardi-OH — Key Updates from the 2026 ADA Standards