Summary of Revisions: Standards of Care in Diabetes—2024

Editor's Notes

1. • There is insufficient evidence to support the use of continuous glucose monitoring for screening or diagnosing prediabetes or diabetes. • In the absence of unequivocal hyperglycemia (e.g., hyperglycemic crisis), diagnosis of type 2 diabetes requires confirmatory testing, which can be a different test on the same day or the same test on a different day. • Marked discordance between A1C and repeated blood glucose measurements should raise the possibility of a problem or interference with either test.
2. Does statin therapy increase the risk of developing type 2 diabetes? • Statin therapy may slightly elevate type 2 diabetes risk in high-risk individuals. • In primary and secondary prevention of cardiovascular disease, statin benefits outweigh diabetes risk. • Discontinuing statins based on concerns about increased diabetes risk is not advised. Does pioglitazone have a role in secondary cardiovascular prevention in people at risk for type 2 diabetes? Pioglitazone could reduce stroke and myocardial infarction risks in people with a history of stroke and evidence of insulin resistance or prediabetes. However, the benefit must be weighed against potential weight gain, edema, and increased fracture risk. Lower doses may lessen these adverse effects.
3. Diabetes treatment goals aim to prevent or delay complications and optimize quality of life. These goals should be developed collaboratively with people with diabetes to honor their preferences and values. Comprehensive diabetes care should be provided by an interprofessional team which may include but is not limited to diabetes care and education specialists, primary care and subspecialty clinicians, nurses, registered dietitian nutritionists, exercise specialists, pharmacists, dentists, podiatrists, behavioral health professionals, and community partners such as community health workers and community paramedics. Ongoing treatment necessitates regular follow-up and the active engagement of people with diabetes and their care partners. Comprehensive medical evaluations (described in the table below) and the provision of all recommended vaccinations (cdc.gov/vaccines) are essential components of ongoing diabetes care.
4. ABI, ankle-brachial pressure index; ARBs, angiotensin receptor blockers; CGM, continuous glucose monitors; MDI, multiple daily injections; NAFLD, nonalcoholic fatty liver disease; OSA, obstructive sleep apnea; PAD, peripheral arterial disease. *At 65 years of age or older. +May be needed more frequently in people with diabetes with known chronic kidney disease or with changes in medications that affect kidney function and serum potassium #May also need to be checked after initiation or dose changes of medications that affect these laboratory values (i.e., diabetes medications, blood pressure medications, cholesterol medications, or thyroid medications). ^In people without dyslipidemia and not on cholesterol-lowering therapy, testing may be less frequent. **Should be performed at every visit in people with diabetes with sensory loss, previous foot ulcers, or amputations.
5. ABI, ankle-brachial pressure index; ARBs, angiotensin receptor blockers; CGM, continuous glucose monitors; MDI, multiple daily injections; NAFLD, nonalcoholic fatty liver disease; OSA, obstructive sleep apnea; PAD, peripheral arterial disease. *At 65 years of age or older. +May be needed more frequently in people with diabetes with known chronic kidney disease or with changes in medications that affect kidney function and serum potassium #May also need to be checked after initiation or dose changes of medications that affect these laboratory values (i.e., diabetes medications, blood pressure medications, cholesterol medications, or thyroid medications). ^In people without dyslipidemia and not on cholesterol-lowering therapy, testing may be less frequent. **Should be performed at every visit in people with diabetes with sensory loss, previous foot ulcers, or amputations.
6. ABI, ankle-brachial pressure index; ARBs, angiotensin receptor blockers; CGM, continuous glucose monitors; MDI, multiple daily injections; NAFLD, nonalcoholic fatty liver disease; OSA, obstructive sleep apnea; PAD, peripheral arterial disease. *At 65 years of age or older. +May be needed more frequently in people with diabetes with known chronic kidney disease or with changes in medications that affect kidney function and serum potassium #May also need to be checked after initiation or dose changes of medications that affect these laboratory values (i.e., diabetes medications, blood pressure medications, cholesterol medications, or thyroid medications). ^In people without dyslipidemia and not on cholesterol-lowering therapy, testing may be less frequent. **Should be performed at every visit in people with diabetes with sensory loss, previous foot ulcers, or amputations.
7. ABI, ankle-brachial pressure index; ARBs, angiotensin receptor blockers; CGM, continuous glucose monitors; MDI, multiple daily injections; NAFLD, nonalcoholic fatty liver disease; OSA, obstructive sleep apnea; PAD, peripheral arterial disease. *At 65 years of age or older. +May be needed more frequently in people with diabetes with known chronic kidney disease or with changes in medications that affect kidney function and serum potassium #May also need to be checked after initiation or dose changes of medications that affect these laboratory values (i.e., diabetes medications, blood pressure medications, cholesterol medications, or thyroid medications). ^In people without dyslipidemia and not on cholesterol-lowering therapy, testing may be less frequent. **Should be performed at every visit in people with diabetes with sensory loss, previous foot ulcers, or amputations.
8. Hypoglycemia is categorized into three levels based on blood glucose concentrations and symptom severity. Level 1 is glucose <70 mg/dL (<3.9 mmol/L) but ≥54 mg/dL (≥3.0 mmol/L). Level 2 is glucose <54 mg/dL (<3.0 mmol/L). Level 3 is a severe event characterized by altered mental and/or physical status requiring assistance for treatment of hypoglycemia, irrespective of glucose level.
9. Hypoglycemia is categorized into three levels based on blood glucose concentrations and symptom severity. Level 1 is glucose <70 mg/dL (<3.9 mmol/L) but ≥54 mg/dL (≥3.0 mmol/L). Level 2 is glucose <54 mg/dL (<3.0 mmol/L). Level 3 is a severe event characterized by altered mental and/or physical status requiring assistance for treatment of hypoglycemia, irrespective of glucose level.
10. Learn More Section 7 of the complete ADA Standards of Care in Diabetes—2024 includes a wealth of additional information on blood glucose meters, evidence supporting the use of CGM, various insulin delivery systems, and digital health apps and online programs.
11. * In people with HF, CKD, established CVD, or multiple risk factors for CVD, the decision to use a GLP-1 RA or SGLT2i with proven benefit should be independent of background use of metformin;† A strong recommendation is warranted for people with CVD and a weaker recommendation for those with indicators of high CV risk. Moreover, a higher absolute risk reduction and thus lower numbers needed to treat are seen at higher levels of baseline risk and should be factored into the shared decision-making process. See text for details; ^ Low-dose TZD may be better tolerated and similarly effective; § For SGLT2i, CV/renal outcomes trials demonstrate their efficacy in reducing the risk of composite MACE, CV death, all-cause mortality, MI, HHF, and renal outcomes in individuals with T2D with established/high risk of CVD; # For GLP-1 RA, CVOTs demonstrate their efficacy in reducing composite MACE, CV death, all-cause mortality, MI, stroke, and renal endpoints in individuals with T2D with established/high risk of CVD. ACEi, angiotensin-converting enzyme inhibitor; ACR, albumin-to-creatinine ratio; ARB, angiotensin receptor blocker; ASCVD, atherosclerotic cardiovascular disease; CGM, continuous glucose monitoring; CKD, chronic kidney disease; CV, cardiovascular; CVD, cardiovascular disease; CVOT, cardiovascular outcomes trial; DPP-4i, dipeptidyl peptidase 4 inhibitor; eGFR, estimated glomerular filtration rate; GLP-1 RA, glucagon-like peptide 1 receptor agonist; dual GIP/GLP-1 RA, dual glucose-dependent insulinotropic polypeptide and glucagon-like peptide 1 receptor agonist; HF, heart failure; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction; HHF, hospitalization for heart failure; MACE, major adverse cardiovascular events; MI, myocardial infarction; SDOH, social determinants of health; SGLT2i, sodium-glucose cotransporter 2 inhibitor; T2D, type 2 diabetes; TZD, thiazolidinedione. Adapted from Davies MJ, D’Alessio DA, Fradkin J, et al. Management of hyperglycemia in type 2 diabetes, 2018: a consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care 2018;41:2669–2701.
12. Atherosclerotic cardiovascular disease (ASCVD), encompassing coronary heart disease, cerebrovascular disease, and peripheral artery disease (PAD) presumed to be of atherosclerotic origin, is the primary cause of morbidity and mortality in individuals with diabetes, leading to significant health care costs. Managing multiple risk factors simultaneously can prevent or slow the progression of ASCVD. Heart failure is another major cause of morbidity and mortality from cardiovascular disease. Legend: *An ACE inhibitor (ACEi) or angiotensin receptor blocker (ARB) is suggested to treat hypertension for people with coronary artery disease (CAD) or urine albumin-to-creatinine ratio (UACR) 30–299 mg/g creatinine and strongly recommended for individuals with UACR ≥300 mg/g creatinine. †Dihydropyridine calcium channel blocker (CCB). ‡Thiazide-like diuretic; long-acting agents shown to reduce cardiovascular events, such as chlorthalidone and indapamide, are preferred. BP, blood pressure. Adapted from de Boer IH, Bangalore S, Benetos A, et al. Diabetes and hypertension: a position statement by the American Diabetes Association. Diabetes Care 2017;40:1273–1284
13. eGFR is presented in units of mL/min/1.73 m2. *ACEi or ARB (at maximal tolerated doses) should be first-line therapy for hypertension when albuminuria is present. Otherwise, dihydropyridine CCB or diuretic can also be considered; all three classes are often needed to attain BP targets. †Finerenone is currently the only nonsteroidal MRA with proven clinical kidney and cardiovascular benefits. ACEi, ACE inhibitor; ACR, albumin-to creatinine ratio; ARB, angiotensin receptor blocker; ASCVD, atherosclerotic cardiovascular disease; BP, blood pressure; CCB, calcium channel blocker; CVD, cardiovascular disease; GLP-1 RA, glucagon-like peptide 1 receptor agonist; HTN, hypertension; MRA, mineralocorticoid receptor antagonist; PCSK9i, proprotein convertase subtilisin/kexin type 9 inhibitor; RAS, renin- angiotensin system; SGLT2i, sodium–glucose cotransporter 2 inhibitor; T1D, type 1 diabetes; T2D, type 2 diabetes. Adapted from de Boer IH, Khunti K, Sadusky T, et al. Diabetes management in chronic kidney disease: a consensus report by the American Diabetes Association (ADA) and Kidney Disease: Improving Global Outcomes (KDIGO). Diabetes Care 2022;45:3075–3090.
14. Algorithm to simplify insulin plans for older adults with type 2 diabetes. eGFR, estimated glomerular filtration rate. *Basal insulins: glargine U-100 and U-300, detemir, degludec, and human NPH. †Prandial insulins: short-acting (regular human insulin) or rapid-acting (lispro, aspart, and glulisine). ‡Premixed insulins: 70/30, 75/25, and 50/50 products. §Examples of noninsulin agents include metformin, sodium–glucose cotransporter 2 inhibitors, dipeptidyl peptidase 4 inhibitors, and glucagon-like peptide 1 receptor agonists. ||See previous page for more information. Adapted with permission from Munshi MN, Slyne C, Segal AR, Saul N, Lyons C, Weinger K. Simplification of insulin regimen in older adults and risk of hypoglycemia. JAMA Intern Med 2016;176:1023–1025.
15. Management of new-onset diabetes in you with overweight or obesity with clinical suspicion of type 2 diabetes. A1C 8.5% = 69 mmol/mol. Adapted from Arslanian S, Bacha F, Grey M, Marcus MD, White NH, Zeitler P. Evaluation and management of youth-onset type 2 diabetes: a position statement by the American Diabetes Association. Diabetes Care 2018;41:2648–2668. BGM, blood glucose monitoring; DKA, diabetic ketoacidosis: HHNK, hyperosmolar hyperglycemic nonketotic syndrome; IV, intravenous; MDI, multiple daily injection.
16. The preconception care of people with diabetes is detailed in Table 15.1 in the complete ADA Standards of Care in Diabetes—2024.