What changed recently

Algorithm 2.0 refines the 2025 EASO framework using 62 randomised trials with evidence through 21 November 2025, sharpening the head-to-head comparisons of total body weight loss across available drugs. The liver domain was expanded beyond MASH resolution to include improvement in liver fibrosis as a treatment target.

The 2026 edition added a new pathophysiology introduction drawing on 40-year DCCT/EDIC follow-up, discussed the eye effects of GLP-1 receptor agonists including NAION and retinopathy progression, added the Ipswich touch test to neuropathy assessment, and revised Rec 12.22 to stress combination therapy for neuropathic pain. Foot care sections now cover home foot-temperature monitoring, expanded WIfI staging, and emerging evidence that GLP-1 RAs may cut lower-extremity amputations.

The 2026 edition added a recommendation to use a dual GIP/GLP-1 receptor agonist in type 2 diabetes with symptomatic heart failure with preserved ejection fraction, and reworked the MASLD/MASH guidance so a GLP-1 RA with proven hepatic benefit is preferred, with pioglitazone or a dual GIP/GLP-1 RA as alternatives. Guidance on continuing GLP-1-based therapy in advanced chronic kidney disease was also expanded.

For insulin-treated diabetes the 2026 edition broadened continuous glucose monitoring to be offered at diagnosis and at any later point (Rec 9.25), and strengthened the recommendation that automated insulin delivery systems be offered to eligible adults. A new recommendation also addresses screening for insulin need and ketoacidosis risk in immune checkpoint inhibitor-associated diabetes.

The 2025 update to AACE's 2016 obesity guidance moved diagnosis away from BMI alone toward adiposity-based criteria and complication-driven staging, and reframed treatment success around metabolic health and complication resolution rather than weight loss percentage. It also added explicit hierarchies of preferred medications matched to each obesity-related complication, reflecting the arrival of highly effective incretin-based agents.

The 2022 consensus report replaced the 2018 report and its 2019 update, raising weight management to equal standing with glycaemic control in the treatment algorithm and recommending SGLT2 inhibitors or GLP-1 receptor agonists for cardiorenal protection independent of HbA1c or metformin use. It also added explicit attention to social determinants of health, health system factors, sleep and physical activity.

The 2022 edition replaced the 2014 NOF Clinician's Guide and introduced a distinct 'very high fracture risk' category, for which osteoanabolic agents such as teriparatide, abaloparatide or romosozumab are recommended as initial therapy rather than being reserved for bisphosphonate failure. It also added explicit guidance on treatment sequencing and on following an anabolic course with an antiresorptive to preserve gains.

This update to the earlier (2003, 2008 and 2015) consensus documents moved late-night salivary cortisol to the front line for screening and recurrence detection, advised measuring dexamethasone levels alongside cortisol to cut false-positive suppression tests, and incorporated newly approved medical therapies such as osilodrostat and mifepristone into the treatment algorithm. It also set an expectation of lifelong monitoring for recurrence and persistent comorbidity after surgery.

The 2019 ESCEO/IOF guidance updated the 2013 European guidance by replacing a two-tier risk split with a three-tier FRAX-based stratification into low, high and very high fracture risk, with decision algorithms that direct very-high-risk women toward more potent or parenteral therapy up front. It also set explicit calcium (800-1200 mg/day) and cholecalciferol (800-1000 IU/day) intake targets for women at increased fracture risk.

The 2016 ATA guidelines replaced the 2011 ATA/AACE hyperthyroidism guidelines, giving third-generation TSH-receptor antibody testing a central role in establishing the cause of thyrotoxicosis and in deciding whether antithyroid drugs can be stopped or should be continued. They also revised antithyroid drug management in pregnancy and added preoperative assessment and repletion of calcium and vitamin D before thyroidectomy.

The 2015 ATA guidelines revised the 2009 edition, introducing sonographic pattern-based risk categories that set size thresholds for fine-needle aspiration so that many nodules under 1 cm no longer warrant biopsy, and adding guidance on molecular marker testing for indeterminate cytology. Overall management shifted toward risk-adapted, less aggressive care to limit overdiagnosis and overtreatment.