Editor’s Perspective

October’s selection covers the new ADA/EASD consensus on type 2 diabetes, the management of nondiagnostic thyroid fine needle aspiration, the safety of SGLT2 inhibitors in people aged 75 and over, and a review of pituitary adenomas in older patients. Three of the four concern older adults, in whom treatment decisions increasingly rest on frailty and comorbidity rather than age alone.

Research Highlights

1. Management of Type 2 Diabetes, 2026: A Consensus Report by the ADA and EASDt

Guideline Focus:

Joint ADA and EASD update of the 2022 consensus, broadening the scope from glucose lowering to holistic care of type 2 diabetes and its associated long-term conditions.

Key Messages:

• SGLT2 inhibitors and/or GLP-1-based therapies should be considered early, potentially from diagnosis, for organ protection, and used in people with established or high risk of CVD, heart failure or CKD independent of metformin.
• Metformin is no longer obligatory first-line therapy. Some may prefer to continue it, as the evidence for benefit independent of metformin comes from subgroup analyses.
• Combination of an SGLT2 inhibitor and GLP-1-based therapy should be considered in people with concomitant CVD, CKD or heart failure.
• Finerenone reduced cardiovascular (HR 0.86) and kidney (HR 0.77) outcomes in diabetic kidney disease. Colchicine is newly discussed for established ASCVD, with an approximately 25% relative reduction in MACE and no difference by diabetes status.
• An HbA1c of 48–53 mmol/mol or lower is reasonable for most adults, and 48 mmol/mol or lower may suit early-onset disease or therapy without hypoglycaemia risk. The CGM target is time in range above 70%.

Clinical Takeaway:

Weight loss of 10–15% is framed as a route to disease modification and remission. Hypercortisolism should be considered when hyperglycaemia persists despite multiple agents.

2. Management of Nondiagnostic Thyroid Fine Needle Aspiration Cytology Nodules Based on TI-RADS Risk Assessment

Study Design:

Retrospective cohort of 342 nodules with initial nondiagnostic FNA, from 3,717 biopsies at a high-volume Canadian clinic.

Key Findings:

• The initial nondiagnostic rate was 9.2%. Repeat FNA was again nondiagnostic in 27.6% overall and in 46–50% of TR1–2 nodules.
• The overall observed malignancy rate was 1.8%. No malignancy was found in 163 TR1–3 nodules, compared with 3.2% in TR4 and 4.2% in TR5.

Clinical Takeaway:

The authors propose ultrasound surveillance for TR1–3 nodules and repeat FNA for TR4–5. Median follow-up was 10 months and all biopsies were performed by expert operators.

3. Safety of Sodium-Glucose Cotransporter 2 Inhibitors in Older Adults With Type 2 Diabetes: A Cohort Study

Study Design:

Population-based cohort from British Columbia of adults aged 75 and over starting an SGLT2 inhibitor (4,997) or a DPP-4 inhibitor (1,289) between 2021 and 2023, using propensity score weighting.

Key Findings:

• Compared with DPP-4 inhibitors, SGLT2 inhibitors were associated with lower risks of acute kidney injury (HR 0.76, 95% CI 0.60–0.95) and all-cause hospitalisation (HR 0.87, 95% CI 0.77–0.98).
• There was no difference in infection, diabetic ketoacidosis, falls or fractures, although confidence intervals for the latter three were wide.

Clinical Takeaway:

In this observational study, SGLT2 inhibitor initiation was not associated with increased harm in people aged 75 and over.

Review Article

Pituitary Adenomas in Older Patients: Approaches, Challenges, and Future Directions

Review Focus:

Twenty years of data on pituitary adenomas diagnosed at age 60 and over, and how they differ from those in younger patients.

Key Messages:

• In postmenopausal women, 93–94% of prolactinomas are macroadenomas. Dopamine agonists normalise prolactin in 86–94%.
• Acromegaly and Cushing’s disease present with milder or atypical features, and cortisol tests are less reliable in older people.
• Nonfunctioning adenomas account for 90–100% of new adenomas after age 80. Surgical complication rates in selected patients are broadly similar to those in younger patients.

Clinical Takeaway:

Management should be guided by frailty and patient wishes rather than chronological age, in centres with multidisciplinary pituitary expertise.

For Further Reading

• Management of type 2 diabetes, 2026: a consensus report by the ADA and EASD: https://doi.org/10.1007/s00125-026-06855-7
• Management of nondiagnostic thyroid fine needle aspiration cytology nodules based on TI-RADS risk assessment: https://doi.org/10.1530/ETJ-26-0237
• Safety of sodium-glucose cotransporter 2 inhibitors in older adults with type 2 diabetes: a cohort study: https://doi.org/10.2337/dc26-1316
• Pituitary adenomas in older patients: approaches, challenges, and future directions: https://doi.org/10.1093/ejendo/lvag183

Closing Note

Several items this month address how evidence applies to older adults. Trial populations underrepresent people over 75, and the observational data and expert reviews summarised here are intended to support individualised decisions in this group.

Dr Tejhmal Rehman
Editor of PES Monthly Endocrine Round-Up
MRCP(UK), MRCP(Endo), FRCP(London), EBEEDM, CCT(UK)
Consultant Endocrinologist
Executive Member, Pakistan Endocrine Society

Dr Ali Asghar
MRCP(UK), FACE, FRCP(Edin), FRCP(London)
Consultant Endocrinologist
President, Pakistan Endocrine Society

Disclaimer: This newsletter provides educational commentary on recent endocrine literature and does not replace clinical judgment or local guidelines.