Glycaemic control remains central in type 2 diabetes mellitus management: key learnings from the latest International Diabetes Federation guidelines

• Type 2 diabetes mellitus has high prevalence in low-to-middle–income countries. • Access to new organ-protective, glucose-lowering drugs is limited in these regions • The 2025 International Diabetes Federation (IDF) guidelines recognise these issues. • The IDF guidelines propose two standards of care: ‘optimal care’ or ‘basic care’ • Both standards of care focus on good glycaemic control to prevent complications. Type 2 diabetes mellitus has high prevalence in low-to-middle–income countries. Access to new organ-protective, glucose-lowering drugs is limited in these regions The 2025 International Diabetes Federation (IDF) guidelines recognise these issues. The IDF guidelines propose two standards of care: ‘optimal care’ or ‘basic care’ Both standards of care focus on good glycaemic control to prevent complications. The 2025 International Diabetes Federation (IDF) guidelines recognise global disparities in healthcare access, with ∼ 80% of people with type 2 diabetes mellitus (T2D) living in low-to-middle–income countries (LMICs). A panel of international experts discussed the evidence underlying these updated guidelines. Randomised trials demonstrate cardiovascular-kidney protection with sodium–glucose cotransporter 2 inhibitors (SGLT2is) and glucagon-like peptide-1 receptor agonists (GLP-1 RAs) in high-risk people with T2D, although their role among those with low-risk disease remains less clear. Whilst advocating for the need to improve access to newer glucose-lowering drugs (GLDs) in LMICs, the IDF guidelines propose two standards-of-care (‘optimal’ or ‘basic’), with the following key messages: (i) early glycaemic control using conventional GLDs prevents complications and preserves quality of life; (ii) multifactorial management using effective GLDs and organ-protective drugs (e.g. statins and renin–angiotensin–aldosterone system inhibitors) improve outcomes; (iii) individualised regimens with shared decision-making and treatment persistence maximises benefits and minimises harm; (iv) metformin is a foundation therapy, with no evidence supporting first-line SGLT2i or GLP-1 RA monotherapy in low-risk individuals; (v) sulphonylureas are highly effective and affordable GLDs, making them important options (particularly in low-resource settings); and (vi) initial combination therapy achieves early glycaemic control with increased durability versus stepwise GLD addition.