2025-ADA-SOC-Slide-Deck-all-recommendations-FINAL-12-9-24.pptx

The American Diabetes
Association’s Standards of Care in
Diabetes—2025
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Standards of Care
in Diabetes—2025
(Standards of Care)

Intended to provide clinicians,
patients, researchers, payers, and
other interested individuals with the
components of diabetes care,
general treatment goals, and tools
to evaluate the quality of care.
Standards of Care
in Diabetes—2025

• Search of scientific diabetes
literature over past year
• Recommendations revised per
new evidence
• Professional Practice Committee
• External peer review
• Reviewed by the ADA’s Board of
Directors
• Living Standards
• Funded out of the ADA’s general
revenues
• Does not use industry support
EVIDENCE
PROCESS
FUNDING

The ADA’s Standards of Care—a Living
Document
• Beginning with the ADA’s 2018 Standards of Care in Diabetes, the Standards document
became a “living” document where notable updates are incorporated
• A description of the Living Standards updates is available at
professional.diabetes.org/standards-of-care/living-standards-update

The ADA’s Standards of Care—a Living
Document
• Updates will be made in response to important events inclusive of, but not
limited to:
 Approval of new treatments (medications or devices) with the potential to
impact patient care;
 Publication of new findings that support a change to a recommendation
and/or evidence level of a recommendation; or
 Publication of a consensus document endorsed by the ADA that
necessitates an update of the Standards to align content of the documents

Evidence-Grading System
Introduction:
Standards of Care in Diabetes - 2025. Diabetes Care 2025;48(Suppl. 1):S1-S5

Table of Contents
1. Improving Care and Promoting Health in Populations
2. Diagnosis and Classification of Diabetes
3. Prevention or Delay of Diabetes and Associated Comorbidities
4. Comprehensive Medical Evaluation and Assessment of Comorbidities
5. Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes
6. Glycemic Goals and Hypoglycemia
7. Diabetes Technology
8. Obesity and Weight Management for the Prevention and Treatment of Type 2 Diabetes
9. Pharmacologic Approaches to Glycemic Treatment
10. Cardiovascular Disease and Risk Management
11. Chronic Kidney Disease and Risk Management
12. Retinopathy, Neuropathy, and Foot Care
13. Older Adults
14. Children and Adolescents
15. Management of Diabetes in Pregnancy
16. Diabetes Care in the Hospital
17. Diabetes and Advocacy

Section 1.
Improving Care and Promoting
Health in Populations
(https://doi.org/10.2337/dc25-S001)

Diabetes and Population Health
1.1 Ensure treatment decisions are timely, rely on evidence-based guidelines, capture key elements within the social
determinants of health, and are made collaboratively with people with or at risk for diabetes and caregivers based on
individual preferences, prognoses, comorbidities, and informed financial considerations. B
1.2 Align approaches to diabetes management with evidence-based care models. These models emphasize person-
centered team care, integrated long-term treatment approaches to diabetes and comorbidities, and ongoing
collaborative communication and goal setting between all team members and with people with diabetes. A
1.3 Care systems should facilitate in-person and virtual team-based care, include those knowledgeable and
experienced in diabetes management as part of the team, and utilize patient registries, decision support tools,
proactive care planning, and community involvement to meet needs of individuals with diabetes. B
1.4 Assess diabetes management, risk factors, and complications (Table 4.1) using reliable and relevant data
metrics to improve processes of care and health outcomes, with attention to care costs, individual preferences and
goals for care, and treatment burden. B
1.5 Health systems should adopt a culture of quality improvement, implement benchmarking programs, and engage
interprofessional teams to support sustainable and scalable process changes to improve quality of care and health
outcomes. A
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Tailoring Treatment for Social Context
1.6 Health systems should assess and address disparities in diabetes care and health outcomes (e.g.,
by stratifying clinical quality data by factors such as insurance status, race, ethnicity, preferred
language for health care discussions, disability, and other social determinants of health). C
1.7 During clinical encounters, assess for social determinants of health, including food insecurity, A
housing insecurity, financial barriers, health insurance and health care access, environmental and
neighborhood factors, and social capital/social community support, B to inform treatment decisions,
with referral to appropriate local community resources.
1.8 Provide people with diabetes additional self-management support from lay health coaches,
navigators, or community health workers when available. A
1.9 Consider the involvement of community health workers to support management of diabetes and
cardiovascular risk factors, especially in underserved communities and health care systems. B
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Improving Care and Promoting Health in Populations:

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Table 1.1 (continued)

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Section 2.
Diagnosis and Classification of Diabetes

Diagnostic Tests for Diabetes
2.1a Diagnose diabetes based on A1C or plasma glucose criteria. Plasma glucose criteria
include either the fasting plasma glucose (FPG), 2-h plasma glucose (2-h PG) during a 75-g
oral glucose tolerance test (OGTT), or random glucose accompanied by classic
hyperglycemic symptoms/crises (Table 2.1). B
2.1b In the absence of unequivocal hyperglycemia (e.g., hyperglycemic crises), diagnosis
requires confirmatory testing (Table 2.1). B
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Diagnosis and Classification of Diabetes:

Use of A1C for Screening and Diagnosis of
Diabetes
2.2a The A1C test should be performed using a method that is certified by the National
Glycohemoglobin Standardization Program (NGSP) as traceable to the Diabetes Control and
Complications Trial (DCCT) reference assay. B
2.2b Point-of-care A1C testing for diabetes screening and diagnosis should be restricted to devices
approved for diagnosis by the U.S. Food and Drug Administration at Clinical Laboratory Improvement
Amendments–certified laboratories that perform testing of moderate complexity or higher by trained
personnel. B
2.3 Evaluate for the possibility of a problem or interference with either test when there is consistent
and substantial discordance between blood glucose values and A1C test results. B
2.4 In conditions associated with an altered relationship between A1C and glycemia, such as some
hemoglobin variants, pregnancy (second and third trimesters and the postpartum period), glucose-6-
phosphate dehydrogenase deficiency, HIV, hemodialysis, recent blood loss or transfusion, hemolysis,
or erythropoietin therapy, plasma glucose criteria should be used to diagnose diabetes. B
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Standards of Care in Diabetes - 2025. Diabetes Care 2025;48(Suppl. 1):S27-49

Classification
2.5 Classify people with hyperglycemia into appropriate diagnostic categories to aid in
personalized management. E
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Classification (continued)
 Type 1 diabetes (due to autoimmune β-cell destruction, usually leading to absolute insulin
deficiency, including latent autoimmune diabetes in adults)
 Type 2 diabetes (due to a nonautoimmune progressive loss of adequate β-cell insulin
secretion, frequently on the background of insulin resistance)
 Specific types of diabetes due to other causes, e.g., monogenic diabetes syndromes,
diseases of the exocrine pancreas, and drug- or chemical-induced diabetes
 Gestational diabetes mellitus (diabetes diagnosed in the second or third trimester of
pregnancy that was not clearly overt diabetes prior to gestation or other types of diabetes
occurring throughout pregnancy, such as type 1 diabetes).
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Type 1 Diabetes
2.6 Screening for presymptomatic type 1 diabetes may be done by detection of autoantibodies to
insulin, glutamic acid decarboxylase (GAD), islet antigen 2 (IA-2), or zinc transporter 8 (ZnT8). B
2.7 Autoantibody-based screening for presymptomatic type 1 diabetes should be offered to those
with a family history of type 1 diabetes or otherwise known elevated genetic risk. B
2.8 Having multiple confirmed islet autoantibodies is a risk factor for clinical diabetes. Testing for
dysglycemia may be used to further forecast near-term risk (Table 2.4). When multiple islet
autoantibodies are identified, referral to a specialized center for further evaluation and/or
consideration of a clinical trial or approved therapy to potentially delay development of clinical
diabetes should be considered. B
2.9 Standardized islet autoantibody tests are recommended for classification of diabetes in
adults who have phenotypic risk factors that overlap with those for type 1 diabetes (e.g., younger
age at diagnosis, unintentional weight loss, ketoacidosis, or short time to insulin treatment). E
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Fig 2.1

Prediabetes and Type 2 Diabetes
2.10 Screening for risk of prediabetes and type 2 diabetes with an assessment of risk factors or
validated risk calculator should be done in asymptomatic adults. B
2.11a Testing for prediabetes or type 2 diabetes in asymptomatic people should be considered in
adults of any age with overweight or obesity who have one or more risk factors (Table 2.5). B
2.11b For all other people, screening should begin at age 35 years. B
2.11c In people without prediabetes or diabetes after screening, repeat screening recommended at a
minimum of 3-year intervals is reasonable, sooner with symptoms or change in risk (e.g., weight gain).
C
2.12 To screen for prediabetes and type 2 diabetes, FPG, 2-h PG during 75-g OGTT, and A1C are
each appropriate (Table 2.1 and Table 2.2). B
2.13 When using OGTT as a screening tool for prediabetes or diabetes, adequate carbohydrate intake
(at least 150 g/day) should be assured for 3 days prior to testing. E
28

Prediabetes and Type 2 Diabetes
(continued)
2.14 Risk-based screening for prediabetes or type 2 diabetes should be considered after the onset of
puberty or after 10 years of age, whichever occurs earlier, in children and adolescents with overweight
(BMI ≥85th percentile) or obesity (BMI ≥95th percentile) and who have one or more risk factors for
diabetes. (See Table 2.6 for evidence grading of risk factors.) B
2.15a Consider screening people for prediabetes or diabetes if they are on certain medications, such
as glucocorticoids, statins, thiazide diuretics, some HIV medications, and second-generation
antipsychotic medications, as these agents are known to increase the risk of these conditions. C
2.15b In people who are prescribed second-generation antipsychotic medications, screen for
prediabetes and diabetes at baseline and repeat 12–16 weeks after medication initiation or sooner, if
clinically indicated, and annually thereafter. B
2.16 People with HIV should be screened for diabetes and prediabetes with an FPG test before
starting antiretroviral therapy, at the time of switching antiretroviral therapy, and 3–6 months after
starting or switching antiretroviral therapy. If initial screening results are normal, FPG should be
checked annually. E
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Pancreatic Diabetes or Diabetes in the
Context of the Exocrine Pancreas
2.17 Screen people for diabetes within 3–6 months following an episode of acute
pancreatitis and annually thereafter. Screening for diabetes is recommended annually for
people with chronic pancreatitis. E
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Cystic Fibrosis-Related Diabetes
2.18 Annual screening for cystic fibrosis-related diabetes (CFRD) with an OGTT should
begin by age 10 years in all people with cystic fibrosis not previously diagnosed with CFRD.
B
2.19 A1C is not recommended as a screening test for CFRD due to low sensitivity.
However, a value of ≥6.5% (≥48 mmol/mol) is consistent with a diagnosis of CFRD. B
2.20 Beginning 5 years after the diagnosis of CFRD, annual monitoring for complications of
diabetes is recommended. E
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Posttranslplantation Diabetes Mellitus
2.21 After organ transplantation, screening for hyperglycemia should be done. A formal
diagnosis of posttransplantation diabetes mellitus (PTDM) is best made once the individual
is stable on an immunosuppressive plan and in the absence of an acute infection. B
2.22 The OGTT is the preferred test to make a diagnosis of PTDM. B
2.23 Immunosuppressive plans shown to provide the best outcomes for individuals and
graft survival should be used, irrespective of PTDM risk. E
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Monogenic Diabetes Syndromes
2.24a Regardless of current age, all people diagnosed with diabetes in the first 6 months of
life should have genetic testing for neonatal diabetes. B
2.24b Children and young adults who do not have typical characteristics of type 1 or type 2
diabetes and family history of diabetes in successive generations (suggestive of an
autosomal dominant pattern of inheritance) should have genetic testing for maturity-onset
diabetes of the young (MODY). B
2.24c In both instances, consultation with a center specializing in diabetes genetics is
recommended to understand the significance of genetic mutations and how best to
approach further evaluation, treatment, and genetic counseling. E
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The diagnosis of monogenic diabetes should be considered in children and adults
diagnosed with diabetes in early adulthood with the following findings:
 Diabetes diagnosed within the first 6 months of life
 Diabetes without typical features of type 1 or type 2 diabetes (negative diabetes-
associated autoantibodies, no obesity, and lacking other metabolic features, especially
strong family history of diabetes)
 Stable, mild fasting hyperglycemia (100–150 mg/dL [5.6–8.5 mmol/L]), stable A1C
between 5.6% and 7.6% (between 38 and 60 mmol/mol), especially if no obesity
The Diagnosis of Monogenic Diabetes

Gestational Diabetes Mellitus
2.25 In individuals who are planning pregnancy, screen those with risk factors (Table 2.5) B
and consider testing all individuals of childbearing potential for undiagnosed prediabetes or
diabetes. E
2.26a Before 15 weeks of gestation, test individuals with risk factors (Table 2.5) B and
consider testing all individuals E for undiagnosed diabetes at the first prenatal visit using
standard diagnostic criteria if not screened preconception.
2.26b Before 15 weeks of gestation, screen for abnormal glucose metabolism to identify
individuals who are at higher risk of adverse pregnancy and neonatal outcomes, are more
likely to need insulin, and are at high risk of a later gestational diabetes mellitus (GDM)
diagnosis. B
2.26c Screen for early abnormal glucose metabolism with dysglycemia using FPG 110–125
mg/dL (6.1-6.9 mmol/L) or A1C 5.9–6.4%(41-47 mmol/mol). B
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Gestational Diabetes Mellitus (continued)
2.27 Screen for GDM at 24–28 weeks of gestation in pregnant individuals not previously
found to have diabetes or high-risk abnormal glucose metabolism detected earlier in the
current pregnancy. A
2.28 Screen individuals with GDM for prediabetes or diabetes at 4–12 weeks postpartum,
using the 75-g OGTT and clinically appropriate nonpregnancy diagnostic criteria. B
2.29 Individuals with a history of GDM should have lifelong screening for the development
of prediabetes or diabetes every 1–3 years. B
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Gestational Diabetes Mellitus
GDM diagnosis (Table 2.8) can be accomplished with either of two
strategies:
 The “one-step” 75-g OGTT derived from the IADPSG criteria, or
 The older “two-step” approach with a 50-g (nonfasting) screen followed by
a 100-g OGTT for those who screen positive based on the work of
Carpenter-Coustan’s interpretation of the older O’Sullivan and Mahan
criteria.

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Section 3.
Prevention or Delay of Diabetes and Associated Comorbidities

Overall Recommendations
3.1 In people with prediabetes, monitor for the development of type 2 diabetes at least annually;
modify frequency of testing based on individual risk assessment. E
3.2 In people with presymptomatic type 1 diabetes, monitor for disease progression using A1C
approximately every 6 months and 75-g oral glucose tolerance test (i.e., fasting and 2-h plasma
glucose) annually; modify frequency of monitoring based on individual risk assessment based on age,
number and type of autoantibodies, and glycemic metrics. E
45

Lifestyle Behavior Change for Type 2
Diabetes Prevention
3.3 Refer adults with overweight or obesity at high risk of type 2 diabetes, as seen in the Diabetes
Prevention Program (DPP), to an intensive lifestyle behavior change program to achieve and maintain
a weight reduction of at least 7% of initial body weight through healthy reduced-calorie diet and
≥150min/week of moderate-intensity physical activity. A
3.4 Prescribe an eating pattern known to be effective in preventing type 2 diabetes to individuals with
prediabetes. A variety of eating patterns, such as Mediterranean style, intermittent fasting, and low
carbohydrate, have shown benefit. B
3.5 Given the cost-effectiveness of lifestyle behavior modification programs for diabetes prevention,
such diabetes prevention programs should be offered to adults at high risk of type 2 diabetes. A
Diabetes prevention programs should be covered by third-party payors, and inconsistencies in access
should be addressed. E
3.6 Based on individual preference, certified technology-assisted diabetes prevention programs may
be effective in preventing type 2 diabetes and should be considered. B
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Pharmacologic Interventions to Delay
Type 2 Diabetes
3.7 Metformin for the prevention of type 2 diabetes should be considered in adults at high risk of type
2 diabetes, as typified by the DPP, especially those aged 25–59 years with BMI ≥35 kg/m2
, higher
fasting plasma glucose (e.g., ≥110 mg/dL [≥ 6 mmol/L]), and higher A1C (e.g., 6.0% [≥42 mmol/mol]),
and in individuals with prior gestational diabetes mellitus. A
3.8 Long-term use of metformin may be associated with vitamin B12 deficiency; consider periodic
assessment of vitamin B12 level in metformin-treated individuals, especially in those with anemia or
peripheral neuropathy. B
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Prevention of Vascular Disease and
Mortality
3.9 Prediabetes is associated with heightened cardiovascular risk; therefore, screening for and
treatment of modifiable risk factors for cardiovascular disease are suggested. B
3.10 Statin therapy may increase the risk of type 2 diabetes in people at high risk of developing type 2
diabetes. In such individuals, glucose status should be monitored regularly and diabetes prevention
approaches reinforced. It is not recommended that statins be avoided or discontinued for this adverse
effect. B
3.11 In people with a history of stroke and evidence of insulin resistance and prediabetes, pioglitazone
may be considered to lower the risk of stroke or myocardial infarction. However, this benefit needs to
be balanced with the increased risk of weight gain, edema, and fractures. A Lower doses may mitigate
the risk of adverse effects but may be less effective. C
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Person-Centered Care Goals
3.12 In adults with overweight or obesity at high risk of type 2 diabetes, care goals should include
weight loss and maintenance, minimizing the progression of hyperglycemia, and attention to
cardiovascular risk. B
3.13 Pharmacotherapy (e.g., for weight management, minimizing the progression of hyperglycemia,
and cardiovascular risk reduction) should be considered to support person-centered care goals. B
3.14 More intensive preventive approaches should be considered in individuals who are at particularly
high risk of progression to diabetes, including individuals with BMI ≥ 35 kg/m2
, those at higher glucose
levels (e.g., fasting plasma glucose 110–125 mg/dL [6.1–6.9 mmol/L], 2-h postchallenge glucose 173–
199 mg/dL [9.6–11.0 mmol/L], and A1C ≥6.0% [≥ 42 mmol/mol]), and individuals with a history of
gestational diabetes mellitus. A
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Pharmacologic Interventions to Delay
Symptomatic Type 1 Diabetes
3.15 Teplizumab-mzwv infusion to delay the onset of symptomatic type 1 diabetes (stage 3) should be
discussed with selected individuals aged ≥8 years with stage 2 type 1 diabetes. Treatment should be
in a setting with appropriately trained personnel. B
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Section 4.
Comprehensive Medical Evaluation and Assessment of
Comorbidities

Person-Centered Collaborative Care
4.1 A communication style that uses person-centered, culturally sensitive, and strength-
based language and active listening; elicits individual preferences and beliefs; and
assesses literacy, numeracy, and potential barriers to care should be used to optimize
health outcomes and health-related quality of life. B
4.2 People with diabetes can benefit from a coordinated interprofessional team that 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, and behavioral health professionals. C
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53
Comprehensive Medical Evaluation and Assessment of Comorbidities:

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Comprehensive Medical Evaluation
4.3 A complete medical evaluation should be performed at the initial visit and follow-up, as
appropriate, to:
 Confirm the diagnosis and classify diabetes. A
 Assess glycemic status and previous treatment. A
 Evaluate for diabetes complications, potential comorbid conditions, and overall health
status. A
 Identify care partners and support system. E
 Assess social determinants of health and structural barriers to optimal health and health
care. A
 Review risk factor management in the person with established diabetes. A
 Begin engagement with the person with diabetes in the formulation of a care
management plan including initial goals of care. A
 Develop a plan for continuing care. A 55

Comprehensive Medical Evaluation
(continued)
4.4 Ongoing management should be guided by the assessment of overall health and
functional status, diabetes complications, cardiovascular risk, hypoglycemia risk, and
shared decision-making to set therapeutic goals. B
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Table 4.2

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Table 4.2

Immunizations
4.5 Provide routinely recommended vaccinations for children and adults with diabetes as
indicated by age (see Table 4.3). A
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Autoimmune Diseases
4.6 Screen people with type 1 diabetes for autoimmune thyroid disease soon after
diagnosis and thereafter at repeated intervals if clinically indicated. B
4.7 Adults with type 1 diabetes should be screened for celiac disease in the presence of
gastrointestinal symptoms, signs, laboratory manifestations, or clinical suspicion suggestive
of celiac disease. B
66

Bone Health
4.8 Assess fracture risk in older adults with diabetes as a part of routine care in diabetes
clinical practice, according to risk factors and comorbidities. A
4.9 Monitor bone mineral density using dual-energy X-ray absorptiometry in older adults
with diabetes (aged ≥65 years) and younger individuals with diabetes and multiple risk
factors every 2–3 years (Table 4.4). A
4.10 Consider the potential adverse impact on skeletal health when selecting
pharmacological options to lower glucose levels in people with diabetes. Avoiding
medications with a known association with higher fracture risk (e.g., thiazolidinediones and
sulfonylureas) is recommended, particularly for those at elevated risk for fractures. B
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Bone Health (continued)
4.11 To reduce the risk of falls and fractures, glycemic management goals should be
individualized for people with diabetes at a higher risk of fracture. C Prioritize use of
glucose-lowering medications that are associated with low risk for hypoglycemia to avoid
falls. B
4.12 Advise people with diabetes on their intake of calcium (1,000–1,200 mg/day) and
vitamin D to ensure it meets the recommended daily allowance for those at risk for fracture,
either through their diet or supplemental means. B
4.13 Antiresorptive medications and osteoanabolic agents should be recommended for
older adults with diabetes who are at higher risk of fracture, including those with low bone
mineral density with a T-score ≤ -2.0, history of fragility fracture, or elevated Fracture Risk
Assessment Tool score (≥3% for hip fracture or ≥20% for major osteoporotic fracture). B
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Cognitive Impairment/Dementia
4.14 In the presence of cognitive impairment, diabetes treatment plans should be simplified
as much as possible and tailored to minimize the risk of hypoglycemia. B
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Dental Care
4.15 People with diabetes should be referred for a dental exam at least once per year. E
4.16 Coordinate efforts between the medical and dental teams to appropriately adjust
glucose-lowering medication and treatment plans prior to and in the post-dental procedure
period as needed. B
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Disability
4.17 Assess for disability at the initial visit and for decline in function at each subsequent
visit in people with diabetes. If a disability is impacting functional ability or capacity to
manage their diabetes, a referral should be made to an appropriate health care professional
specializing in disability (e.g., physical medicine and rehabilitation specialist, physical
therapist, occupational therapist, or speech-language pathologist). C
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Low Testosterone in Men
4.18 In men with diabetes or prediabetes, inquire about sexual health (e.g., low libido and
erectile dysfunction [ED]). If symptoms and/or signs of hypogonadism are detected (e.g.,
low libido, ED, and depression), screen with a morning serum total testosterone level. B
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Erectile Dysfunction
4.19 In men with diabetes or prediabetes, screen for ED, particularly in those with high
cardiovascular risk, retinopathy, cardiovascular disease, chronic kidney disease, peripheral
or autonomic neuropathy, longer duration of diabetes, depression, and hypogonadism, and
in those who are not meeting glycemic goals. B
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Female Sexual Dysfunction
4.20 In women with diabetes or prediabetes, inquire about sexual health by screening for
desire (libido), arousal, and orgasm difficulties, particularly in those who experience
depression and/or anxiety and those with recurrent urinary tract infections. B
4.21 In postmenopausal women with diabetes or prediabetes, screen for symptoms and/or
signs of genitourinary syndrome of menopause, including vaginal dryness and dyspareunia.
B
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Metabolic-Associated Steatotic Liver Disease and
Metabolic-Associated Steatohepatitis - Screening
4.22a Screen adults with type 2 diabetes or with prediabetes, particularly those with obesity
or other cardiometabolic risk factors or established cardiovascular disease, for their risk of
having or developing cirrhosis related to metabolic dysfunction-associated steatohepatitis
(MASH) using a calculated fibrosis-4 index (FIB-4) (derived from age, ALT, AST, and
platelets [mdcalc.com/calc/2200/fibrosis4-fib-4-index-liver-fibrosis]), even if they have
normal liver enzymes. B
4.22b Adults with diabetes or prediabetes with persistently elevated plasma
aminotransferase levels for >6 months and low FIB-4 should be evaluated for other causes
of liver disease. B
4.23 Adults with type 2 diabetes or prediabetes with a FIB-4 ≥1.3 should have additional
risk stratification by liver stiffness measurement with transient elastography, or, if
unavailable, the enhanced liver fibrosis (ELF) test. B
4.24 Refer adults with type 2 diabetes or prediabetes at higher risk for significant liver
fibrosis (i.e., as indicated by FIB-4, liver stiffness measurement, or ELF) to a
gastroenterologist or hepatologist for further evaluation and management. B
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Metabolic-Associated Steatohepatitis - Management
4.25 Adults with type 2 diabetes or prediabetes, particularly with overweight or obesity, who have
metabolic dysfunction-associated steatotic liver disease (MASLD) should be recommended lifestyle
changes using an interprofessional approach that promotes weight loss, ideally within a structured
nutrition plan and physical activity program for cardiometabolic benefits B and histological
improvement. C
4.26 In adults with type 2 diabetes, MASLD, and overweight or obesity, consider using a glucagon-
like peptide 1 (GLP-1) receptor agonist (RA) or a dual glucose-dependent insulinotropic
polypeptide (GIP) and GLP-1 RA for the treatment of obesity with potential benefits in MASH as an
adjunctive therapy to lifestyle interventions for weight loss. B
4.27a In adults with type 2 diabetes and biopsy-proven MASH or those at high risk for liver fibrosis
(based on noninvasive tests), pioglitazone, a GLP-1 RA, or a dual GIP and GLP-1 RA is preferred
for glycemic management because of potential beneficial effects on MASH. B
4.27b Combination therapy with pioglitazone plus GLP-1 RA can be considered for the treatment of
hyperglycemia in adults with type 2 diabetes with biopsy-proven MASH or those at high risk of liver
fibrosis (identified with noninvasive tests) because of potential beneficial effects on MASH. B
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Metabolic-Associated Steatohepatitis – Management
(continued)
4.28 For consideration of treatment with a thyroid hormone receptor-β agonist in adults with
type 2 diabetes or prediabetes with MASLD with moderate (F2) or advanced (F3) liver
fibrosis on liver histology, or by a validated imaging-based or blood-based test, refer to a
gastroenterologist or hepatologist with expertise in MASLD management. A
4.29 Treatment initiation and monitoring should be individualized and within the context of
an interprofessional team that includes a gastroenterologist or hepatologist, consideration
of individual preferences, and a careful shared-decision cost-benefit discussion. B
4.30a In adults with type 2 diabetes and MASLD, use of glucose-lowering therapies other
than pioglitazone or GLP-1 RAs may be continued as clinically indicated, but these
therapies lack evidence of benefit in MASH. B
4.30b Insulin therapy is the preferred agent for the treatment of hyperglycemia in adults
with type 2 diabetes with decompensated cirrhosis. C
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Metabolic-Associated Steatohepatitis – Management
(continued)
4.31a Adults with type 2 diabetes and MASLD are at increased cardiovascular risk;
therefore, comprehensive management of cardiovascular risk factors is recommended. B
4.31b Statin therapy is safe in adults with type 2 diabetes and compensated cirrhosis from
MASLD and should be initiated or continued for cardiovascular risk reduction as clinically
indicated. B In people with decompensated cirrhosis, statin therapy should be used with
caution, and close monitoring is needed, given limited safety and efficacy data. B
4.32a Consider metabolic surgery in appropriate candidates as an option to treat MASH in
adults with type 2 diabetes B and to improve cardiovascular outcomes. B
4.32b Metabolic surgery should be used with caution in adults with type 2 diabetes with
compensated cirrhosis from MASLD B and is not recommended in decompensated
cirrhosis. B
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Section 5.
Facilitating Positive Behaviors and Well-being to Improve Health
Outcomes

Diabetes Self-Management Education and
Support
5.1 All people with diabetes should be advised to participate in developmentally and
culturally appropriate diabetes self-management education and support (DSMES) to
facilitate informed decision-making, self-care behaviors, problem-solving, and active
collaboration with the health care team. A
5.2 Provide DSMES at diagnosis, annually and/or when not meeting treatment goals, when
complicating factors develop (e.g., medical, functional, and psychosocial), and when
transitions in life and care occur. E
5.3 Routinely assess clinical outcomes, health status, and well-being as key goals of
DSMES. C
5.4 Screen for behavioral health concerns at the same critical times as evaluating the need
for DSMES and refer to a qualified behavioral health professional if indicated to increase
engagement in DSMES. E
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5. Facilitating Positive Behaviors and Well-being to Improve Health Outcomes

Support (continued)
5.5 DSMES should be culturally appropriate and responsive to individual preferences,
needs, and values and may be offered in group or individual settings. A Such education
and support should be documented and made available to members of the entire diabetes
care team. E
5.6 Consider offering DSMES via telehealth and/or digital interventions as needed to meet
individual preferences, address barriers to access, and improve satisfaction. B
5.7 DSMES can improve outcomes and reduce costs, so reimbursement by third-party
payors is recommended. B
5.8 Identify and address barriers to DSMES that exist at the payor, health system, clinic,
health care professional, and individual levels. E
5.9 Screen for and include social determinants of health in guiding design and delivery of
DSMES C with the ultimate goal of health equity across all populations.
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Support (continued)
In addition to providing DSMES upon diagnosis, there are additional critical time points
when the need for DSMES should be evaluated by the health care professional and/or
interprofessional team, with referrals made as needed:
 Annually and/or when not meeting treatment goals, whichever is more frequent
 When complicating factors (e.g., health conditions, physical or functional limitations,
emotional factors, and basic living needs) that influence self-management develop
 When transitions in life and care occur
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Medical Nutrition Therapy
5.10 An individualized medical nutrition therapy program, as needed to achieve treatment
goals, and provided by a registered dietitian nutritionist, preferably one who has
comprehensive knowledge and experience in diabetes care, is recommended for all people
with type 1 or type 2 diabetes, prediabetes, and gestational diabetes mellitus. A
5.11 Because diabetes medical nutrition therapy can result in cost savings B and improved
cardiometabolic outcomes, A medical nutrition therapy should be adequately reimbursed by
insurance. E
5.12 Provide weight management treatment based on nutrition, physical activity, and
behavioral therapy for all people with overweight or obesity, aiming for at least 3–7% weight
loss. A
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Medical Nutrition Therapy (continued)
5.13 For diabetes prevention and management of people with prediabetes or diabetes,
recommend individualized meal plans that keep nutrient quality, total calories, and
metabolic goals in mind, B as data do not support a specific macronutrient pattern.
5.14 Eating patterns should emphasize key nutrition principles (inclusion of nonstarchy
vegetables, whole fruits, legumes, lean proteins, whole grains, nuts and seeds, and low-fat
dairy or nondairy alternatives) and minimize consumption of red meat, sugar-sweetened
beverages, sweets, refined grains, processed and ultraprocessed foods in people with
prediabetes and diabetes. B
5.15 Consider reducing overall carbohydrate intake for adults with diabetes to improve
glycemia, as this approach may be applied to a variety of eating patterns that meet
individual needs and preferences. B
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5.16 Health care professionals should inquire about intake of dietary supplements and
counsel as necessary. Supplementation with micronutrients (e.g., vitamins and minerals,
such as magnesium or chromium) or herbs or spices (e.g., cinnamon and aloe vera) for
glycemic benefits is not recommended. C
5.17 Counsel against β-carotene supplementation, as there is evidence of harm for certain
individuals and it confers no benefit. B
5.18 Advise adults with diabetes and those at risk for diabetes who consume alcohol to not
exceed the recommended daily limits. B Advise abstainers to not start drinking alcohol,
even in moderation.
5.19 Educate people with diabetes about the signs, symptoms, and self-management of
delayed hypoglycemia after drinking alcohol, especially when using insulin or insulin
secretagogues. The importance of monitoring glucose after drinking alcoholic beverages to
reduce hypoglycemia risk should be emphasized. B
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5.20 Counsel people with diabetes to limit sodium consumption to <2,300 mg/day, as
clinically appropriate, B and that the best way to achieve this is through limiting
consumption of processed foods. B
5.21 Counsel people with prediabetes and diabetes that water is recommended over
nutritive and nonnutritive sweetened beverages. A
5.22 Counsel people with diabetes and those at risk for diabetes that nonnutritive
sweeteners can be used instead of sugar-sweetened products if consumed in moderation
and for the short term to reduce overall calorie and carbohydrate intake. B
5.23 Screen people with diabetes and those at risk for diabetes for malnutrition, especially
those who have undergone metabolic surgery A and those being treated with weight loss
pharmacologic therapies. B
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5.24 Emphasize minimally processed, nutrient-dense, high-fiber sources of carbohydrate
(at least 14 g fiber per 1,000 kcal). B
5.25 Advise people with diabetes and those at risk to replace sugar-sweetened beverages
(including fruit juices) with water or low-calorie or no-calorie beverages as much as possible
to manage glycemia and reduce risk for cardiometabolic disease B and minimize
consumption of foods with added sugar that have the capacity to displace healthier, more
nutrient-dense food choices. A
5.26 Regardless of diabetes classification, individuals treated with sodium-glucose
cotransporter 2 inhibitors should avoid a ketogenic eating pattern, be educated on the signs
of ketoacidosis and methods of risk mitigation and provided with appropriate tools for
accurate ketone measurement (i.e., serum β-hydroxybutyrate), and be instructed to avoid
fasting and maintain appropriate insulin therapy. E
5.27 Provide education on the glycemic impact of carbohydrate, A fat, and protein B
tailored to an individual’s needs, insulin plan, and preferences to optimize mealtime insulin
dosing.
90

5.28 When using fixed insulin doses, individuals should be provided with education about
consistent patterns of carbohydrate intake with respect to time and amount while
considering the insulin action time, as it can result in improved glycemia and reduce the risk
for hypoglycemia. B
5.29 People with diabetes and those at risk for diabetes are advised to incorporate more
plant-based protein sources (e.g., nuts, seeds, and legumes) as part of an overall diverse
eating pattern to reduce cardiovascular disease risk. B
5.30 Counsel people with diabetes to consider an eating plan emphasizing elements of a
Mediterranean eating pattern, which is rich in monounsaturated and polyunsaturated fats
and long-chain fatty acids such as fatty fish, nuts, and seeds, to reduce cardiovascular
disease risk A and improve glucose metabolism. B
5.31 Counsel people with diabetes and those at risk for diabetes to limit intake of foods high
in saturated fat (e.g., red meat, full-fat dairy, butter, and coconut oil) to help reduce
cardiovascular disease risk. A
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Facilitating Positive Heath Behaviors and Well-being to Improve Health Outcomes:

Religious Fasting
5.32 Use the International Diabetes Federation along with Diabetes and Ramadan
International Alliance comprehensive prefasting risk assessment to generate a risk score
for the safety of religious fasting. Provide fasting-focused education to minimize risks. B
5.33 Assess and optimize treatment plan, dose, and timing for people with diabetes well in
advance of religious fasting to reduce risk of hypoglycemia, dehydration, hyperglycemia,
and/or ketoacidosis. B
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Physical Activity
5.34 Counsel youth with type 1 diabetes C or type 2 diabetes B to engage in 60 min/day or
more of moderate or vigorous-intensity aerobic activity, with muscle-strengthening and
bone-strengthening activities at least 3 days/week, and to limit the amount of time being
spent sedentary, including recreational screen time. C
5.35 Counsel most adults with type 1 diabetes C and type 2 diabetes B to engage in 150
min or more of moderate-to vigorous-intensity aerobic activity per week, spread over at
least 3 days/week, with no more than 2 consecutive days without activity. Shorter durations
(minimum 75 min/week) of vigorous-intensity or interval training may be sufficient for more
physically fit individuals.
5.36 Counsel adults with type 1 diabetes C and type 2 diabetes B to engage in 2–3
sessions/week of resistance exercise on nonconsecutive days.
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Physical Activity (continued)
5.37 Recommend flexibility training and balance training 2–3 times/week for older adults
with diabetes. Yoga and tai chi may be included based on individual preferences to
increase flexibility, muscular strength, and balance. C
5.38 For all people with diabetes, evaluate baseline physical activity and time spent in
sedentary behavior (i.e., quiet sitting, lying, and leaning). For people who do not meet
activity guidelines, encourage an increase in physical activities (e.g., walking, yoga,
housework, gardening, swimming, and dancing) above baseline. B Counsel that prolonged
sitting should be interrupted at least every 30 min for blood glucose benefits. C
5.39 Counsel adults and youth treated with weight management pharmacotherapy or
metabolic surgery that meeting physical activity recommendations, and in particular
muscle-strengthening exercises, may be beneficial for maintaining lean body mass. E
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Smoking Cessation: Tobacco, e-Cigarettes,
and Cannabis
5.40 Advise all people with diabetes not to use cigarettes and other tobacco products or e-
cigarettes. A
5.41 Ask people with diabetes routinely about the use of cigarettes or other tobacco
products. After identification of use, recommend and refer for combination treatment
consisting of both tobacco/smoking cessation counseling and pharmacologic therapy. A
5.42 Advise people with type 1 diabetes C and those with other forms of diabetes at risk for
diabetic ketoacidosis E not to use recreational cannabis in any form.
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Supporting Positive Health Behaviors
5.43 Behavioral strategies should be used to support diabetes self-management and
engagement in health behaviors (e.g., taking medications, using diabetes technologies, and
engaging in physical activity and healthy eating) to promote optimal health-related quality of
life and health outcomes. A
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Psychosocial Care
5.44 Psychosocial care should be provided to all people with diabetes, with the goal of
optimizing health-related quality of life and health outcomes. Such care should be
integrated with routine medical care and delivered by trained health care professionals
using a collaborative, person-centered, culturally informed approach. A
5.45 Implement screening protocols for psychosocial concerns, including diabetes distress,
depression, anxiety, fear of hypoglycemia, and disordered eating behaviors. Screen at least
annually or when there is a change in disease, treatment, or life circumstances. C
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Psychosocial Care (continued)
5.46 When indicated, refer to behavioral health professionals or other trained health care
professionals, ideally those with experience in diabetes, for further assessment and
treatment for symptoms of diabetes distress, depression, suicidality, anxiety, treatment-
related fear of hypoglycemia, disordered eating, and/or cognitive capacities. Such
specialized psychosocial care should use age-appropriate standardized and validated tools
and treatment approaches. B
5.47 Consider developmental factors and use age-appropriate validated tools for
psychosocial screening in people with diabetes. E
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Diabetes Distress
5.48 Screen for diabetes distress at least annually in people with diabetes, caregivers, and
family members, and repeat screening when treatment goals are not met, at transitional
times, and/or in the presence of diabetes complications. Health care professionals can
address diabetes distress and may consider referral to a qualified behavioral health
professional, ideally one with experience in diabetes, for further assessment and treatment
if indicated. B
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Anxiety
5.49 Screen people with diabetes for anxiety symptoms. Health care professionals can
discuss diabetes-related worries and should consider referral to a qualified behavioral
health professional for further assessment and treatment if anxiety symptoms indicate
interference with diabetes self-management behaviors or quality of life. B
5.50 Screen people with diabetes at risk for hypoglycemia or fear of hypoglycemia,
especially if they have experienced severe and/or frequent hypoglycemic events. B
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Depression
5.51 Conduct at least annual screening of depressive symptoms in all people with diabetes
and more frequently among those with a history of depression. Use age-appropriate,
validated depression screening measures, recognizing that further evaluation will be
necessary for individuals who have a positive screen. B
5.52 Rescreen for depression at diagnosis of complications or when there are significant
changes in medical status. B
5.53 Refer to qualified behavioral health professionals or other trained health care
professionals with experience using evidence-based treatment approaches for depression
in conjunction with collaborative care with the diabetes treatment team. A
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Disordered Eating Behavior
5.54 Screen for disordered or disrupted eating using validated screening measures. In
addition, a review of the medical treatment plan is recommended to identify potential
treatment-related effects on hunger/caloric intake. B
5.55 Consider reevaluating the treatment plan of people with diabetes who present with
symptoms of disordered eating behavior, an eating disorder, or disrupted patterns of eating,
in consultation with a qualified professional. Key qualifications include familiarity with
diabetes disease physiology, treatments for diabetes and disordered eating behaviors, and
weight-related and psychological risk factors for disordered eating behaviors. B
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Serious Mental Illness
5.56 Provide an increased level of support for people with diabetes and serious mental
illness through enhanced monitoring of and assistance with diabetes self-management
behaviors. B
5.57 Monitor changes in body weight, glycemia, and lipids in adolescents and adults with
diabetes who are prescribed second-generation antipsychotic medications; adjust the
treatment plan accordingly, if needed. C
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Cognitive Capacity and Impairment
5.58 Cognitive capacity should be monitored throughout the life span for all individuals with
diabetes, particularly in those who have documented cognitive disabilities, those who
experience severe hypoglycemia, very young children, and older adults. B
5.59 If cognitive capacity changes or appears to be suboptimal for decision-making and/or
behavioral self-management, referral for a formal assessment should be considered. E
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Sleep Health
5.60 Consider screening for sleep health in people with diabetes, including symptoms of
sleep disorders, disruptions to sleep due to diabetes symptoms or management needs, and
worries about sleep. Refer to sleep medicine specialists and/or qualified behavioral health
professionals as indicated. B
5.61 Counsel people with diabetes to practice sleep-promoting routines and habits. A
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Section 6.
Glycemic Goals and Hypoglycemia

Glycemic Assessment
6.1 Assess glycemic status by A1C A and/or continuous glucose monitoring (CGM) metrics
such as time in range, time above range, and time below range. B Fructosamine or CGM
can be used for glycemic monitoring when an alternative to A1C is required. B
6.2 Assess glycemic status at least two times a year, and more frequently (e.g., every 3
months) for individuals not meeting glycemic goals or with recent treatment changes,
frequent or severe hypoglycemia or hyperglycemia, or changes in health status, or during
periods of rapid growth and development in youth. E
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Glycemic Goals and Hypoglycemia:

Glycemic Goals
6.3a An A1C goal of <7% (<53 mmol/mol) is appropriate for many nonpregnant adults
without severe hypoglycemia or frequent hypoglycemia affecting health or quality of life. A
6.3b A goal time in range of >70% in people using CGM is appropriate for many
nonpregnant adults. B
6.3c A goal percent time <70 mg/dL (<3.9 mmol/L) of <4% (or <1% for older adults) and a
goal percent time <54 mg/dL (<3.0 mmol/L) of <1% are recommended in people using CGM
to prevent hypoglycemia. Deintensify or modify therapy if these goals are not met. B
6.4 Based on health care professional judgment and the preference of the person with
diabetes, achievement of lower A1C levels than the goal of 7% (53 mmol/mol) may be
acceptable and even beneficial if it can be achieved safely without frequent or severe
hypoglycemia or other adverse effects of treatment. B
6.5 Less stringent glycemic goals may be appropriate for individuals with limited life
expectancy or where the harms of treatment are greater than the benefits. B
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Glycemic Goals (continued)
6.6 Deintensify hypoglycemia-causing medications (insulin, sulfonylureas, or meglitinides),
or switch to a medication class with lower hypoglycemia risk, for individuals who are at high
risk for hypoglycemia, within individualized glycemic goals. B
6.7 Deintensify diabetes medications for individuals for whom the harms and/or burdens of
treatment may be greater than the benefits, within individualized glycemic goals. B
6.8 Reassess glycemic goals based on the individualized criteria shown in Fig. 6.2. E
6.9 Set a glycemic goal during consultations to improve outcomes. A
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122

Cardiovascular Disease and Type 2
Diabetes
123
As outlined in more detail in Section 9, “Pharmacologic Approaches to
Glycemic Treatment,” and Section 10, “Cardiovascular Disease and Risk
Management,” the cardiovascular benefits of SGLT2 inhibitors or GLP-1 RAs
are not contingent upon A1C lowering; therefore, initiation can be considered
in people with type 2 diabetes and CVD independent of the current A1C,
A1C goal, or metformin therapy. Based on these considerations, the
following two strategies are offered (66):
 1. If already on dual therapy or multiple glucose-lowering therapies and not
on an SGLT2 inhibitor or a GLP-1 RA, consider switching to one of these
agents with proven cardiovascular benefit.
 2. Introduce SGLT2 inhibitors or GLP-1 RAs in people with CVD at A1C
goal (independent of metformin) for cardiovascular benefit, independent of
baseline A1C or individualized A1C goal.

124

Hypoglycemia Assessment, Prevention,
and Treatment
6.10 Review history of hypoglycemia at every clinical encounter for all individuals at risk for
hypoglycemia, and evaluate hypoglycemic events as indicated. C
6.11 Screen individuals at risk for hypoglycemia for impaired hypoglycemia awareness at least
annually and when clinically appropriate. E Refer to a trained health care professional for
evidence-based intervention to improve hypoglycemia awareness. A
6.12 Screen individuals at high risk for hypoglycemia or with severe and/or frequent
hypoglycemia for fear of hypoglycemia at least annually and when clinically appropriate. E Refer
to a trained health care professional for evidence-based intervention. A
6.13 Clinicians should consider an individual’s risk for hypoglycemia (see Table 6.5) when
selecting diabetes medications and glycemic goals. E
6.14 Use of CGM is beneficial and recommended for individuals at high risk for hypoglycemia. A
6.15 Glucose is the preferred treatment for the conscious individual with glucose <70 mg/dL
(<3.9 mmol/L), although any form of carbohydrate that contains glucose may be used. Avoid
using foods or beverages high in fat and/or protein for initial treatment of hypoglycemia. Fifteen
minutes after initial treatment, repeat the treatment if hypoglycemia persists. B 125

Hypoglycemia Assessment, Prevention,
and Treatment (continued)
6.16 Glucagon should be prescribed for all individuals taking insulin or at high risk for
hypoglycemia. A Family, caregivers, school personnel, and others providing support to
these individuals should know its location and be educated on how to administer it.
Glucagon preparations that do not have to be reconstituted are preferred. B
6.17 All individuals taking insulin A or at risk for hypoglycemia C should receive structured
education for hypoglycemia prevention and treatment, with ongoing education for those
who experience hypoglycemic events.
6.18 One or more episodes of level 2 or 3 hypoglycemia should prompt reevaluation of the
treatment plan, including deintensifying or switching diabetes medications if appropriate. E
6.19 Regularly assess cognitive function; if impaired or declining cognition is found, the
clinician, person with diabetes, and caregiver should increase vigilance for hypoglycemia. B
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Hyperglycemic Crises: Diagnosis,
Management, and Prevention
6.20 Review history of hyperglycemic crises (e.g., diabetic ketoacidosis and hyperglycemic
hyperosmolar state) at every clinical encounter for all individuals with diabetes at risk for
these events. C
6.21 Provide structured education on the recognition, prevention, and management of
hyperglycemic crisis to all individuals with type 1 diabetes, those with type 2 diabetes who
have experienced these events, and people at high risk for these events. B
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Section 7.
Diabetes Technology

General Device Principles
7.1 Diabetes devices should be offered to people with diabetes. A
7.2 Initiation of continuous glucose monitoring (CGM) should be offered to people with type 1
diabetes early in the disease, even at time of diagnosis. A
7.3 The type(s) and selection of devices should be individualized based on a person’s specific
needs, circumstances, preferences, and skill level. In the setting of an individual whose diabetes
is partially or wholly managed by someone else (e.g., a young child or a person with cognitive
impairment or dexterity, psychosocial issues, and/or physical limitations), the caregiver’s skills
and preferences are integral to the decision-making process. E
7.4 When prescribing a device, ensure that people with diabetes and caregivers receive initial
and ongoing education and training, either in person or remotely, and ongoing evaluation of
technique, results, and the ability to utilize data, including uploading or sharing data (if
applicable), to monitor and adjust therapy. C
7.5 Health care professionals working with diabetes technology should ensure that
competencies are established within the health care team based on their specific roles and
within specific settings. E
136

General Device Principles (continued)
7.6 People with diabetes who have been using CGM, continuous subcutaneous insulin
infusion (CSII), and/or automated insulin delivery (AID) for diabetes management should
have continued access across third-party payors, regardless of age or A1C levels. E
7.7 Students should be supported at school in the use of diabetes technology, such as
CGM systems, CSII, connected insulin pens, and AID systems, as recommended or
prescribed by their health care team. E
7.8 Recommend early initiation, including at diagnosis, of CGM, CSII, and AID depending
on a person’s or caregiver’s needs and preferences. C
7.9 Standardized reports for all CGM, CSII, AID, and connected insulin devices with a
minimum of a single-page report, such as the ambulatory glucose profile and weekly
summary, should be available and utilized. Options for daily and weekly reports and raw
data should be available. E
137

Blood Glucose Monitoring
7.10 People with diabetes should be provided with blood glucose monitoring (BGM) devices
as indicated by their circumstances, preferences, and treatment. People using CGM
devices must also have access to BGM at all times. A
7.11 People who are taking insulin and using BGM should be encouraged to check their
blood glucose levels when appropriate based on their insulin therapy. This may include
checking when fasting, prior to meals and snacks, after meals, at bedtime, in the middle of
the night, prior to, during, and after exercise, when hypoglycemia is suspected, after
treating low blood glucose levels until they are normoglycemic, when hyperglycemia is
suspected, and prior to and while performing critical tasks such as driving. B
7.12 Health care professionals should be aware of the differences in accuracy amongst
blood glucose meters. Only meters approved by the U.S. Food and Drug Administration
(FDA) (or comparable regulatory agencies for other geographical locations) with proven
accuracy should be used, with unexpired test strips purchased from a pharmacy or licensed
distributor and properly stored. E
138

Blood Glucose Monitoring (continued)
7.13 Although BGM in people on noninsulin therapies has not consistently shown clinically
significant reductions in A1C levels, it may be helpful when modifying meal plans, physical
activity plans, and/or medications (particularly medications that can cause hypoglycemia) in
conjunction with a treatment adjustment program. E
7.14 Consider potential interference of medications and substances on glucose levels
measured by blood glucose meters. B
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140
Diabetes Technology:

Continuous Glucose Monitoring Devices
7.15 Recommend real-time CGM (rtCGM) A or intermittently scanned CGM (isCGM) for
diabetes management to youth C and adults B with diabetes on any type of insulin therapy.
The choice of CGM device should be made based on the individual’s circumstances,
preferences, and needs.
7.16 Consider using rtCGM and isCGM in adults with type 2 diabetes treated with glucose-
lowering medications other than insulin to achieve and maintain individualized glycemic
goals. The choice of device should be made based on the individual’s circumstances,
preferences, and needs. B
7.17 In people with diabetes on insulin therapy, rtCGM devices should be used as close to
daily as possible for maximal benefit. A isCGM devices should be scanned frequently, at
minimum once every 8 h, to avoid gaps in data. A People with diabetes should have
uninterrupted access to their supplies to minimize gaps in CGM. A
141

Continuous Glucose Monitoring Devices
(continued)
7.18 CGM can help achieve glycemic goals (e.g., time in range and time above range) A
and A1C goal B in type 1 diabetes and pregnancy and may be beneficial for other types of
diabetes in pregnancy. E
7.19 In circumstances when consistent use of CGM is not feasible, consider periodic use of
personal or professional CGM to adjust medication and/or lifestyle. C
7.20 Skin reactions, either due to irritation or allergy, should be assessed and addressed to
aid in successful use of devices. E
7.21 People who wear CGM devices should be educated on potential interfering
substances and other factors that may affect accuracy. C
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145

Insulin Delivery (syringes and pens)
7.22 For people with insulin-requiring diabetes on multiple daily injections (MDI), insulin
pens are preferred in most cases. Still, insulin syringes may be used for insulin delivery
considering individual and caregiver preference, insulin type, availability in vials, dosing
therapy, cost, and self-management capabilities. C
7.23 Insulin pens or insulin injection aids are recommended for people with dexterity issues
or vision impairment or when decided by shared decision-making to facilitate the accurate
dosing and administration of insulin. C
7.24 Offer connected insulin pens for people with diabetes taking multiple daily insulin
injections. B
7.25 FDA-approved insulin dose calculators/decision support systems may be helpful for
calculating insulin doses. B
146

Insulin Delivery (Pumps and Automated
Delivery Systems)
7.26 AID systems should be the preferred insulin delivery method to improve glycemic
outcomes and reduce hypoglycemia and disparities in youth and adults with type 1 diabetes
A and other types of insulin-deficient diabetes E who are capable of using the device (either
by themselves or with a caregiver). Choice of an AID system should be made based on the
individual’s circumstances, preferences, and needs. A
7.27 Insulin pump therapy, preferably with CGM, should be offered for diabetes
management to youth and adults on MDI with type 2 diabetes who can use the device
safely (either by themselves or with a caregiver). The choice of device should be made
based on the individual’s circumstances, preferences, and needs. A
7.28 Individuals with diabetes who have been using CSII should have continued access
across third-party payors. E
147

Insulin Delivery (Open-Source Automated
Insulin Dosing)
7.29 Support and provide diabetes management advice to people with diabetes who
choose to use an open-source closed-loop system. B
148

Digital Health Technology
7.30 Consider combining technology (CGM, insulin pump, and/or diabetes apps) with online
or virtual coaching to improve glycemic outcomes in individuals with diabetes or
prediabetes. B
149

Inpatient Care
7.31 In people with diabetes wearing personal CGM, the use of CGM should be continued
when clinically appropriate during hospitalization, with confirmatory point-of-care glucose
measurements for insulin dosing and hypoglycemia assessment and treatment under an
institutional protocol. B
7.32 Continue use of insulin pump or AID in people with diabetes who are hospitalized
when clinically appropriate, with confirmatory POC blood glucose measurements for insulin
dose decisions and hypoglycemia assessment and treatment. This is contingent upon
availability of necessary supplies, resources, and training, ongoing competency
assessments, and implementation of institutional diabetes technology protocols. C
150

Section 8.
Obesity and Weight Management for the Prevention and Treatment of Type 2 Diabetes

Assessment and Monitoring of the
Individual with Overweight or Obesity
8.1 Use person-centered, nonjudgmental language that fosters collaboration between individuals and
health care professionals, including person-first language (e.g., “person with obesity” rather than
“obese person” and “person with diabetes” rather than “diabetic person”). E
8.2a To support the diagnosis of obesity, measure height and weight to calculate BMI and perform
additional measurements of body fat distribution, like waist circumference, waist-to-hip ratio, and/or
waist-to-height ratio if BMI is indeterminant. E
8.2b Monitor obesity-related anthropometric measurements at least annually to inform treatment
considerations. During active weight management treatment, increase monitoring to at least every 3
months. E
8.3 Accommodations should be made to provide privacy during anthropometric measurements. E
152

Assessment and Monitoring of the Individual with
Overweight or Obesity (continued)
8.4 In people with type 2 diabetes and overweight or obesity, weight management should
represent a primary goal of treatment along with glycemic management. A
8.5 Provide weight management treatment, aiming for any magnitude of weight loss. Weight
loss of 3–7% of baseline weight improves glycemia and other intermediate cardiovascular
risk factors. A Sustained loss of >10% of body weight usually confers greater benefits,
including disease-modifying effects and possible remission of type 2 diabetes, and may
improve long-term cardiovascular outcomes and mortality. B
8.6 Individualize initial treatment approaches for obesity (i.e., lifestyle and nutritional
therapy, pharmacologic agents, or metabolic surgery) A based on the person’s medical
history, life circumstances, preferences, and motivation. C Consider combining treatment
approaches if appropriate. E
153

Nutrition, Physical Activity, and Behavioral
Therapy
8.7 Nutrition, physical activity, and behavioral therapy are recommended for people with
type 2 diabetes and overweight or obesity to achieve both weight and health outcome
goals. B
8.8a Interventions including high frequency of counseling (≥16 sessions in 6 months) with
focus on nutrition changes, physical activity, and behavioral strategies to achieve a 500–
750 kcal/day energy deficit should be recommended for weight loss and should be
considered when available. A
8.8b If access to such interventions is limited, consider alternative structured programs
delivering behavioral counseling (face-to-face or remote). E
8.9 Nutrition recommendations should be individualized to the person’s preferences and
nutritional needs. Use nutritional plans that create an energy deficit, regardless of
macronutrient composition, to achieve weight loss. A
154

Nutrition, Physical Activity, and Behavioral
Therapy (continued)
8.10 When developing a plan of care, consider systemic, structural, cultural, and
socioeconomic factors that may impact nutrition patterns and food choices, such as food
insecurity and hunger, access to healthful food options, and other social determinants of
health. C
8.11 For those who achieve weight loss goals, continue to monitor progress, provide
ongoing support, and recommend continuing interventions to maintain weight goals long
term. E Effective long-term (≥1 year) weight maintenance programs provide monthly contact
and support, include frequent self-monitoring of body weight (weekly or more frequently) and
other self-monitoring strategies (e.g., food diaries or wearables), and encourage regular
physical activity (200–300min/week). A
8.12 Short-term nutrition intervention using structured, very-low-calorie meals (800–1,000
kcal/day) should be prescribed to only carefully selected individuals by trained practitioners
in medical settings with close monitoring. Long-term, comprehensive weight maintenance
strategies and counseling should be integrated to maintain weight loss. B
8.13 Nutritional supplements have not been shown to be effective for weight loss and are not
recommended. A
155

Pharmacotherapy
8.14 Whenever possible, minimize medications for comorbid conditions that are associated
with weight gain. E
8.15 When choosing glucose-lowering medications for people with type 2 diabetes and
overweight or obesity, prioritize medications with beneficial effect on weight. B
8.16 Weight management pharmacotherapy should be considered for people with diabetes
and overweight or obesity along with lifestyle changes. Potential benefits and risks must be
considered. A
8.17 In people with diabetes and overweight or obesity, the preferred pharmacotherapy
should be a glucagon-like peptide 1 receptor agonist or dual glucose-dependent
insulinotropic poly-peptide and glucagon-like peptide 1 receptor agonist with greater weight
loss efficacy (i.e., semaglutide or tirzepatide), especially considering their added weight-
independent benefits (e.g., glycemic and cardiometabolic) A
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Pharmacotherapy (continued)
8.18 Screen people with diabetes and obesity who have lost significant weight for
malnutrition, especially those who have undergone metabolic surgery A and those treated
with weight management pharmacologic therapy. B
8.19 Weight management pharmacotherapy indicated for chronic therapy should be
continued beyond reaching weight loss goals to maintain the health benefits. Sudden
discontinuation of weight management pharmacotherapy often results in weight gain and
worsening of cardiometabolic risk factors. A
8.20 For those not reaching treatment goals, reevaluate weight management therapies and
intensify treatment with additional approaches (e.g., metabolic surgery, additional
pharmacologic agents, and structured lifestyle management programs). A
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Metabolic Surgery
8.21 Consider metabolic surgery as a weight and glycemic management approach in
people with diabetes with BMI ≥ 30.0 kg/m2
(or ≥27.5 kg/m2
in Asian American individuals)
who are otherwise good surgical candidates. A
8.22 Metabolic surgery should be performed in high-volume centers with interprofessional
teams knowledgeable about and experienced in managing obesity, diabetes, and
gastrointestinal surgery
(www.facs.org/quality-programs/accreditation-and-verification/metabolicand-bariatric-
surgeryaccreditation-andquality-improvement-program/). E
8.23 People being considered for metabolic surgery should be evaluated for comorbid
psychological conditions and social and situational circumstances that have the potential to
interfere with surgery outcomes. B
8.24 People who undergo metabolic surgery should receive long-term medical and
behavioral support and routine micronutrient, nutritional, and metabolic status monitoring. B
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Metabolic Surgery (continued)
8.25 If post–metabolic surgery hypoglycemia is suspected, clinical evaluation should
exclude other potential disorders contributing to hypoglycemia, and management should
include education, medical nutrition therapy with a registered dietitian nutritionist
experienced in post-metabolic surgery hypoglycemia, and medication treatment, as
needed. A In individuals with post-metabolic surgery hypoglycemia, use continuous glucose
monitoring to improve safety. C
8.26 In people who undergo metabolic surgery, routinely screen for psychosocial and
behavioral health changes and refer to a qualified behavioral health professional as
needed. C
8.27 Monitor individuals who have undergone metabolic surgery for insufficient weight loss
or weight recurrence at least every 6–12 months. E In those who have insufficient weight
loss or experience weight recurrence, assess for potential predisposing factors and, if
appropriate, consider additional weight loss interventions (e.g., weight management
pharmacotherapy). C
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Obesity and Weight Management for the Prevention and Treatment of Type 2 Diabetes:

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163

Section 9.
Pharmacologic Approaches to Glycemic Treatment

Pharmacologic Therapy for Adults with
Type 1 Diabetes
9.1 Treat most adults with type 1 diabetes with continuous subcutaneous insulin infusion or
multiple daily doses of prandial (injected or inhaled) and basal insulin. A
9.2 For most adults with type 1 diabetes, insulin analogs (or inhaled insulin) are preferred
over injectable human insulins to minimize hypoglycemia risk. A
9.3 Early use of continuous glucose monitoring is recommended for adults with type 1
diabetes to improve glycemic outcomes and quality of life and to minimize hypoglycemia. B
9.4 Automated insulin delivery systems should be offered to all adults with type 1 diabetes.
A
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Type 1 Diabetes (continued)
9.5 To improve glycemic outcomes and quality of life and to minimize hypoglycemia risk,
most adults with type 1 diabetes should receive education on how to match mealtime
insulin doses to carbohydrate intake and fat and protein intake. They should also be taught
how to modify the insulin dose (correction dose) based on concurrent glycemia, glycemic
trends (if available), sick-day management, and anticipated physical activity. B
9.6 Insulin treatment plan and insulin-taking behavior should be reevaluated at regular
intervals (e.g., every 3–6 months) and adjusted to incorporate specific factors that impact
choice of treatment and ensure achievement of individualized glycemic goals. E
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167
Pharmacologic Approaches to Glycemic Treatment:

168

169

170

171

Type 2 Diabetes
9.7 Healthy behaviors, diabetes self-management education and support, avoidance of
therapeutic inertia, and social determinants of health should be included in the glucose-
lowering management of type 2 diabetes. A
9.8 A person-centered shared decision-making approach should guide the choice of
glucose-lowering medications for adults with type 2 diabetes. Use medications that provide
sufficient effectiveness to achieve and maintain intended treatment goals with consideration
of the effects on cardiovascular, kidney, weight, and other relevant comorbidities;
hypoglycemia risk; cost and access; risk for adverse reactions and tolerability; and
individual preferences (Fig. 9.3 and Table 9.2). E
9.9 Combination therapy can be considered in adults with type 2 diabetes at treatment
initiation to shorten time to attainment of individualized treatment goals. A
172

9.10 In adults with type 2 diabetes and established or high risk of atherosclerotic
cardiovascular disease, the treatment plan should include medications with demonstrated
benefits to reduce cardiovascular events (e.g., glucagon-like peptide 1 receptor agonist
[GLP-1 RA] and/or sodium–glucose cotransporter 2 [SGLT2] inhibitor) for glycemic
management and comprehensive cardiovascular risk reduction (irrespective of A1C) (Fig.
9.3 and Table 9.2). A
9.11 In adults with type 2 diabetes who have heart failure (HF) (with either reduced or
preserved ejection fraction), an SGLT2 inhibitor is recommended for both glycemic
management and prevention of HF hospitalizations (irrespective of A1C) (Fig. 9.3). A
9.12 In adults with type 2 diabetes and symptomatic heart failure with preserved ejection
fraction (HFpEF) and obesity, a GLP-1 RA with demonstrated benefits for both glycemic
management and reduction of HF-related symptoms (irrespective of A1C) is recommended.
A
173

9.13 In adults with type 2 diabetes who have CKD (with confirmed estimated glomerular
filtration rate [eGFR] 20–60 mL/min/1.73 m2
and/or albuminuria), an SGLT2 inhibitor or
GLP-1 RA with demonstrated benefit in this population should be used for both glycemic
management (irrespective of A1C) and for slowing progression of CKD and reduction in
cardiovascular events (Fig. 9.3). The glycemic benefits of SGLT2 inhibitors are reduced at
eGFR <45 mL/min/1.73 m2
. A
9.14 In adults with type 2 diabetes and advanced CKD (eGFR <30 mL/min/1.73 m2
), a GLP-
1 RA is preferred for glycemic management due to lower risk of hypoglycemia and for
cardiovascular event reduction. B
9.15 In adults with type 2 diabetes, metabolic dysfunction-associated steatotic liver disease
(MASLD), and overweight or obesity, consider using a GLP-1 RA or a dual glucose-
dependent insulinotropic polypeptide (GIP) and GLP-1 RA with potential benefits in
metabolic dysfunction-associated steatohepatitis (MASH) for glycemic management and as
an adjunctive to healthy interventions for weight loss. B
174

9.16a In adults with type 2 diabetes and biopsy-proven MASH or those at high risk for liver
fibrosis (based on noninvasive tests), pioglitazone, a GLP-1 RA, or a dual GIP and GLP-1
RA is preferred for glycemic management due to potential beneficial effects on MASH. B
9.16b Combination therapy with pioglitazone plus a GLP-1 RA can be considered for the
treatment of hyperglycemia in adults with type 2 diabetes with biopsy-proven MASH or
those at high risk of liver fibrosis identified with noninvasive tests) due to potential beneficial
effects on MASH. B
9.17 Medication plan and medication-taking behavior should be reevaluated at regular
intervals (e.g., every 3–6 months) and adjusted as needed to incorporate specific factors
that impact choice of treatment (Fig. 4.1 and Table 9.2). E
9.18 Treatment modification (intensification or deintensification) for adults not meeting
individualized treatment goals should not be delayed. A
175

9.19 Choice of glucose-lowering therapy modification should take into consideration
individualized glycemic and weight goals, presence of comorbidities (cardiovascular,
kidney, liver, and other metabolic comorbidities), and the risk of hypoglycemia. A
9.20 When initiating a new glucose-lowering medication, reassess the need for and/or dose
of medications with higher hypoglycemia risk (i.e., sulfonylureas, meglitinides, and insulin)
to minimize the risk of hypoglycemia and treatment burden. A
9.21 Concurrent use of dipeptidyl peptidase 4 (DPP-4) inhibitors with a GLP-1 RA or a dual
GIP and GLP-1 RA is not recommended due to lack of additional glucose lowering beyond
that of a GLP-1 RA alone. B
9.22 In adults with type 2 diabetes who have not achieved their individualized weight goals,
additional weight management interventions (e.g., intensification of lifestyle modifications,
structured weight management programs, pharmacologic agents, or metabolic surgery, as
appropriate) are recommended. A
176

9.23 In adults with type 2 diabetes, initiation of insulin should be considered regardless of
background glucose-lowering therapy or disease stage if symptoms of hyperglycemia are
present or when A1C or blood glucose levels are very high (i.e., A1C >10% [>86 mmol/mol]
or blood glucose ≥300 mg/dL [≥ 16.7 mmol/L]). E
9.24 In adults with type 2 diabetes and no evidence of insulin deficiency, a GLP-1 RA,
including a dual GIP and GLP-1 RA, is preferred to insulin (Fig. 9.4). A
9.25 If insulin is used, combination therapy with a GLP-1 RA, including a dual GIP and
GLP-1 RA, is recommended for greater glycemic effectiveness as well as beneficial effects
on weight and hypoglycemia risk for adults with type 2 diabetes. Insulin dosing should be
reassessed upon addition or dose escalation of a GLP-1 RA or dual GIP and GLP-1 RA. A
9.26 In adults with type 2 diabetes who are initiating insulin therapy, continue glucose-
lowering agents (unless contraindicated or not tolerated) for ongoing glycemic and
metabolic benefits (i.e., weight, cardiometabolic, or kidney benefits). A
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179
Figure 9.3 (continued)

180

181

182

183

184

185

186

187

188

189

190

191

Additional Recommendations For All
Individuals with Diabetes
9.27 Monitor for signs of overbasalization during insulin therapy, such as significant bedtime-to-
morning or postprandial-to-preprandial glucose differential, occurrences of hypoglycemia (aware or
unaware), and high glycemic variability. When overbasalization is suspected, a thorough reevaluation
should occur promptly to further tailor therapy to the individual’s needs. E
9.28 Glucagon should be prescribed for all individuals requiring intensive insulin therapy or at high risk
for hypoglycemia. Family, caregivers, school personnel, and others providing support to these
individuals should know its location and be educated on how to administer it. Glucagon preparations
that do not require reconstitution are preferred. B
9.29 Routinely assess all people with diabetes for financial obstacles that could impede their diabetes
management. Clinicians, members of the diabetes care team, and social services professionals
should work collaboratively, as appropriate and feasible, to support these individuals by implementing
strategies to reduce costs, thereby improving their access to evidence-based care. E
9.30 In adults with diabetes and cost-related barriers, consider use of lower-cost medications for
glycemic management (i.e., metformin, sulfonylureas, thiazolidinediones, and human insulin) within
the context of their risks for hypoglycemia, weight gain, cardiovascular and kidney events, and other
adverse effects. E
192

Special Circumstances and Populations
9.31a Use of compounded products that are not approved by the FDA is not recommended
due to uncertainty about their content and resulting concerns about safety, quality, and
effectiveness. E
9.31b If a glucose-lowering medication is unavailable (e.g., in shortage), it is recommended
to switch to a different FDA-approved medication with similar efficacy, as clinically
appropriate. E
9.31c Upon resolution of the unavailability (e.g., shortage), reassess the appropriateness of
resuming the original FDA-approved medication. E
193

Special Circumstances and Populations
(continued)
9.32a Individuals with diabetes of childbearing potential should be counseled on
contraception options A and the impact of some glucose-lowering medications on
contraception efficacy. C
9.32b A person-centered shared decision-making approach to preconception planning is
essential for all individuals with diabetes and of childbearing potential. A Preconception
planning should address attainment of glycemic goals, A the time frame for discontinuing
noninsulin glucose-lowering medications, E and optimal glycemic management in
preparation for pregnancy. A
9.33 Educate individuals with diabetes who are at risk for developing diabetic ketoacidosis
and/or follow a ketogenic eating pattern and who are treated with SGLT inhibitors on the
risks and signs of ketoacidosis and methods of risk mitigation management, and provide
them with appropriate tools for accurate ketone measurement (i.e., serum b-
hydroxybutyrate). E
194

Section 10.
Cardiovascular Disease and Risk Management

196
Cardiovascular Disease and Risk Management:

Hypertension and Blood Pressure
Management – Screening and Diagnosis
10.1 Blood pressure should be measured at every routine clinical visit, or at least every 6
months. Individuals found to have elevated blood pressure without a diagnosis of
hypertension (systolic blood pressure 120–129 mmHg and diastolic blood pressure <80
mmHg) should have blood pressure confirmed using multiple readings, including
measurements on a separate day, to diagnose hypertension. A Hypertension is defined as
a systolic blood pressure ≥130 mmHg or a diastolic blood pressure ≥ 80mmHg based on an
average of two or more measurements obtained on two or more occasions. A Individuals
with blood pressure ≥180/110 mmHg and cardiovascular disease could be diagnosed with
hypertension at a single visit. E
10.2 Counsel all people with hypertension and diabetes to monitor their blood pressure at
home after appropriate education. A
197

Hypertension and Blood Pressure
Management – Treatment Goals
10.3 For people with diabetes and hypertension, blood pressure goals should be
individualized through a shared decision-making process that addresses cardiovascular
risk, potential adverse effects of antihypertensive medications, and individual preferences.
B
10.4 The on-treatment blood pressure goal is <130/80 mmHg, if it can be safely attained. A
10.5 In pregnant individuals with diabetes and chronic hypertension, a blood pressure
threshold of 140/90 mmHg for initiation or titration of therapy is associated with better
pregnancy outcomes than reserving treatment for severe hypertension, with no increase in
risk of small-for-gestational-age birth weight. A There are limited data on the optimal lower
limit, but therapy should be deintensified for blood pressure <90/60 mmHg. E A blood
pressure goal of 110–135/85 mmHg is suggested in the interest of reducing the risk for
accelerated maternal hypertension. A
198

199

200

201

Hypertension and Blood Pressure Management –
Treatment Strategies (Lifestyle Intervention)
10.6 For people with blood pressure >120/80 mmHg, lifestyle intervention consists of
weight loss when indicated, a Dietary Approaches to Stop Hypertension (DASH)-style
eating pattern including reducing sodium and increasing potassium intake, moderation of
alcohol intake, smoking cessation, and increased physical activity. A
202

Treatment Strategies (Pharmacologic Interventions)
10.7 In individuals with confirmed office-based blood pressure ≥130/80 mmHg,
pharmacologic therapy should be initiated and titrated to achieve the recommended blood
pressure goal of <130/80 mmHg. A
10.8 Individuals with confirmed office-based blood pressure ≥ 150/90 mmHg should, in
addition to lifestyle therapy, have prompt initiation and timely titration of two drugs or a
single-pill combination of drugs demonstrated to reduce cardiovascular events in people
with diabetes. A
10.9 Treatment for hypertension should include drug classes demonstrated to reduce
cardiovascular events in people with diabetes. A ACE inhibitors or angiotensin receptor
blockers (ARBs) are recommended first-line therapy for hypertension in people with
diabetes and coronary artery disease. A
10.10 Multiple-drug therapy is generally required to achieve blood pressure goals. Avoid
combinations of ACE inhibitors and ARBs and combinations of ACE inhibitors or ARBs
(including ARBs and neprilysin inhibitors) with direct renin inhibitors. A
203

Treatment Strategies (Pharmacologic Interventions,
continued)
10.11 An ACE inhibitor or ARB, at the maximum tolerated dose indicated for blood pressure
treatment, is the recommended first-line treatment for hypertension in people with diabetes
and urinary albumin-to-creatinine ratio ≥300 mg/g creatinine A or 30–299 mg/g creatinine.
B If one class is not tolerated, the other should be substituted. B
10.12 Monitor for increased serum creatinine and for increased serum potassium levels
when ACE inhibitors, ARBs, and mineralocorticoid receptor antagonists (MRAs) are used,
for hypokalemia when diuretics are used at routine visits, and 7–14 days after initiation or
after a dose change. B
10.13 ACE inhibitors, angiotensin receptor blockers, MRAs, direct renin inhibitors, and
neprilysin inhibitors should be avoided in sexually active individuals of childbearing potential
who are not using reliable contraception and are contraindicated in pregnancy. A
204

Treatment Strategies (Resistant Hypertension)
10.14 Individuals with hypertension who are not meeting blood pressure goals on three
classes of antihypertensive medications (including a diuretic) should be considered for MRA
therapy. A
205

Lipid Management (Lifestyle Intervention)
10.15 Lifestyle modification focusing on weight loss (if indicated); application of a
Mediterranean or DASH eating pattern; reduction of saturated fat and trans fat; increase of
dietary n-3 fatty acids, viscous fiber, and plant stanol and sterol intake; and increased
physical activity should be recommended to improve the lipid profile and reduce the risk of
developing atherosclerotic cardiovascular disease (ASCVD) in people with diabetes. A
10.16 Intensify lifestyle therapy and optimize glycemic management for people with
diabetes with elevated triglyceride levels (≥150 mg/dL [≥1.7 mmol/L]) and/or low HDL
cholesterol (<40 mg/dL [<1.0 mmol/L] for men and <50 mg/dL [<1.3 mmol/L] for women). C
206

Lipid Management (Ongoing Therapy and
Monitoring with Lipid Panel)
10.17 In adults with prediabetes or diabetes not taking statins or other lipid-lowering
therapy, it is reasonable to obtain a lipid profile at the time of diagnosis, at an initial medical
evaluation, annually thereafter, or more frequently if indicated. E
10.18 Obtain a lipid profile at initiation of statins or other lipid-lowering therapy, 4–12 weeks
after initiation or a change in dose, and annually thereafter, as it facilitates monitoring the
response to therapy and informs medication-taking behavior. A
207

Statin Treatment (Primary Prevention)
10.19 For people with diabetes aged 40–75 years without ASCVD, use moderate-intensity
statin therapy in addition to lifestyle therapy. A
10.20 For people with diabetes aged 20–39 years with additional ASCVD risk factors, it may
be reasonable to initiate statin therapy in addition to lifestyle therapy. C
10.21 For people with diabetes aged 40–75 years at higher cardiovascular risk, including
those with one or more additional ASCVD risk factors, high-intensity statin therapy is
recommended to reduce LDL cholesterol by ≥50% of baseline and to obtain an LDL
cholesterol goal of <70 mg/dL (<1.8 mmol/L). A
10.22 For people with diabetes aged 40–75 years at higher cardiovascular risk, especially
those with multiple additional ASCVD risk factors and an LDL cholesterol ≥70 mg/dL (≥1.8
mmol/L), it may be reasonable to add ezetimibe or a PCSK9 inhibitor to maximum tolerated
statin therapy. B
208

Statin Treatment (Primary Prevention,
continued)
10.23 In adults with diabetes aged >75 years already on statin therapy, it is reasonable to
continue statin treatment. B
10.24 In adults with diabetes aged >75 years, it may be reasonable to initiate moderate-
intensity statin therapy after discussion of potential benefits and risks. C
10.25 In people with diabetes intolerant to statin therapy, treatment with bempedoic acid is
recommended to reduce cardiovascular event rates as an alternative cholesterol-lowering
plan. A
10.26 In most circumstances, lipid-lowering agents should be stopped prior to conception
and avoided in sexually active individuals of childbearing potential who are not using
reliable contraception. B In some circumstances (e.g., for individuals with familial
hypercholesterolemia or prior ASCVD event), statin therapy may be continued when the
benefits outweigh risks. E
209

210

Statin Treatment (Secondary Prevention)
10.27 For people of all ages with diabetes and ASCVD, high-intensity statin therapy should
be added to lifestyle therapy. A
10.28 For people with diabetes and ASCVD, treatment with high-intensity statin therapy is
recommended to obtain an LDL cholesterol reduction of ≥50% from baseline and an LDL
cholesterol goal of <55 mg/dL (<1.4 mmol/L). Addition of ezetimibe or a PCSK9 inhibitor
with proven benefit in this population is recommended if this goal is not achieved on
maximum tolerated statin therapy. B
10.29a For individuals who do not tolerate the intended statin intensity, the maximum
tolerated statin dose should be used. E
10.29b For people with diabetes and ASCVD intolerant to statin therapy, PCSK9 inhibitor
therapy with monoclonal antibody treatment, A bempedoic acid therapy, A or PCSK9
inhibitor therapy with inclisiran siRNA E should be considered as an alternative cholesterol-
lowering therapy.
211

212

213

Treatment of Other Lipoprotein Fractions
or Goals
10.30 For individuals with fasting triglyceride levels ≥500mg/dL (≥5.7mmol/L), evaluate for
secondary causes of hypertriglyceridemia and consider medical therapy to reduce the risk
of pancreatitis. C
10.31 In adults with hypertriglyceridemia (fasting triglycerides >150 mg/dL [>1.7 mmol/L] or
nonfasting triglycerides >175mg/dL [> 2.0mmol/L]), clinicians should address and treat
lifestyle factors (obesity and metabolic syndrome), secondary factors (diabetes, chronic
liver or kidney disease and/or nephrotic syndrome, and hypothyroidism), and medications
that raise triglycerides. C
10.32 In individuals with ASCVD or other cardiovascular risk factors on a statin with
managed LDL cholesterol but elevated triglycerides (150–499 mg/dL [1.7–5.6 mmol/L]), the
addition of icosapent ethyl can be considered to reduce cardiovascular risk. B
214

Other Combination Therapy
10.33 Statin plus fibrate combination therapy has not been shown to improve ASCVD
outcomes and is generally not recommended. A
10.34 Statin plus niacin combination therapy has not been shown to provide additional
cardiovascular benefit above statin therapy alone, may increase the risk of stroke with
additional side effects, and is generally not recommended. A
215

Antiplatelet Agents
10.35 Use aspirin therapy (75–162 mg/day) as a secondary prevention strategy in those with
diabetes and a history of ASCVD. A
10.36a For individuals with ASCVD and documented aspirin allergy, clopidogrel (75 mg/day)
should be used. B
10.36b The length of treatment with dual antiplatelet therapy using low-dose aspirin and a
P2Y12 inhibitor in individuals with diabetes after an acute coronary syndrome, acute ischemic
stroke, or transient ischemic attack should be determined by an interprofessional team
approach that includes a cardiovascular or neurological specialist, respectively. E
10.37 Combination therapy with aspirin plus low-dose rivaroxaban should be considered for
individuals with stable coronary and/or peripheral artery disease (PAD) and low bleeding risk
to prevent major adverse limb and cardiovascular events. A
10.38 Aspirin therapy (75–162 mg/day) may be considered as a primary prevention strategy
in those with diabetes who are at increased cardiovascular risk after a comprehensive
discussion with the individual on the benefits versus the comparable increased risk of
bleeding. A 216

Cardiovascular Disease – Screening
10.39a In asymptomatic individuals, routine screening for coronary artery disease is not
recommended, as it does not improve outcomes as long as ASCVD risk factors are treated.
A
10.39b Consider investigations for coronary artery disease in the presence of any of the
following: signs or symptoms of cardiac or associated vascular disease, including carotid
bruits, transient ischemic attack, stroke, claudication, or PAD; or electrocardiogram
abnormalities (e.g., Q waves). E
10.40a Adults with diabetes are at increased risk for the development of asymptomatic
cardiac structural or functional abnormalities (stage B heart failure) or symptomatic (stage
C) heart failure. Consider screening adults with diabetes by measuring a natriuretic peptide
(B-type natriuretic peptide [BNP] or N-terminal pro-BNP [NT-proBNP]) to facilitate
prevention of stage C heart failure. B
217

Cardiovascular Disease – Screening
(continued)
10.40b In asymptomatic individuals with diabetes and abnormal natriuretic peptide levels,
echocardiography is recommended to identify stage B heart failure. A
10.41 In asymptomatic individuals with diabetes and age ≥65 years, microvascular disease
in any location, or foot complications or any end-organ damage from diabetes, screening for
PAD with ankle-brachial index testing is recommended if a PAD diagnosis would change
management. B In individuals with diabetes duration ≥10 years and high cardiovascular
risk, screening for PAD should be considered. E
218

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Cardiovascular Disease – Treatment
10.42 Among people with type 2 diabetes who have established ASCVD or established
kidney disease, a sodium–glucose cotransporter 2 (SGLT2) inhibitor or glucagon-like
peptide 1 (GLP-1) receptor agonist (RA) with demonstrated cardiovascular disease benefit
is recommended as part of the comprehensive cardiovascular risk reduction and/or
glucose-lowering treatment plans. A
10.42a In people with type 2 diabetes and established ASCVD, multiple ASCVD risk factors,
or chronic kidney disease (CKD), an SGLT2 inhibitor with demonstrated cardiovascular
benefit is recommended to reduce the risk of major adverse cardiovascular events and/or
heart failure hospitalization. A
10.42b In people with type 2 diabetes and established ASCVD or multiple risk factors for
ASCVD, a GLP-1 RA with demonstrated cardiovascular benefit is recommended to reduce
the risk of major adverse cardiovascular events. A
220

(continued)
10.42c In people with type 2 diabetes and established ASCVD or multiple risk factors for
ASCVD, combined therapy with an SGLT2 inhibitor with demonstrated cardiovascular
benefit and a GLP-1 RA with demonstrated cardiovascular benefit may be considered for
additive reduction of the risk of adverse cardiovascular and kidney events. A
10.43a In people with type 2 diabetes and established heart failure with either preserved or
reduced ejection fraction, an SGLT2 inhibitor (including SGLT1/2 inhibitor) with proven
benefit in this population is recommended to reduce the risk of worsening heart failure and
cardiovascular death. A
10.43b In people with type 2 diabetes and established heart failure with either preserved or
reduced ejection fraction, an SGLT2 inhibitor with proven benefit in this population is
recommended to improve symptoms, physical limitations, and quality of life. A
10.44 For individuals with type 2 diabetes and CKD with albuminuria treated with maximum
tolerated doses of ACE inhibitor or ARB, recommend treatment with a nonsteroidal MRA
with demonstrated benefit to improve cardiovascular outcomes and reduce the risk of CKD
progression. A 221

(continued)
10.45 In individuals with diabetes with established ASCVD or aged ≥55 years with
additional cardiovascular risk factors, ACE inhibitor or ARB therapy is recommended to
reduce the risk of cardiovascular events and mortality. A
10.46a In individuals with diabetes and asymptomatic stage B heart failure, an
interprofessional approach to optimize guideline-directed medical therapy, which should
include a cardiovascular disease specialist, is recommended to reduce the risk for
progression to symptomatic (stage C) heart failure. A
10.46b In individuals with diabetes and asymptomatic stage B heart failure, ACE inhibitors
or ARBs and β-blockers are recommended to reduce the risk for progression to
symptomatic (stage C) heart failure. A
10.46c In individuals with type 2 diabetes and asymptomatic stage B heart failure or with
high risk of or established cardiovascular disease, treatment with an SGLT inhibitor with
proven heart failure prevention benefit is recommended to reduce the risk of hospitalization
for heart failure. A
222

(continued)
10.46d In individuals with type 2 diabetes, obesity, and symptomatic heart failure with
preserved ejection fraction, therapy with a GLP-1 RA with demonstrated benefit for
reduction of heart failure-related symptoms, physical limitations, and exercise function is
recommended. A
10.46e In individuals with type 2 diabetes and CKD, recommend treatment with a
nonsteroidal MRA with demonstrated benefit to reduce the risk of hospitalization for heart
failure. A
10.46f In individuals with diabetes, guideline-directed medical therapy for myocardial
infarction and symptomatic stage C heart failure is recommended with ACE inhibitors or
ARBs, MRAs, angiotensin receptor or neprilysin inhibitor, β-blockers, and SGLT2 inhibitors,
similar to guideline-directed medical therapy for people without diabetes. A
223

(continued)
10.47 In people with type 2 diabetes with stable heart failure, metformin may be continued
for glucose lowering if estimated glomerular filtration rate remains >30 mL/min/1.73 m2
but
should be avoided in unstable or hospitalized individuals with heart failure. B
10.48 Individuals with type 1 diabetes and those with type 2 diabetes who are ketosis prone
and/or follow a ketogenic eating pattern who are treated with SGLT inhibition should be
educated on the risks and signs of ketoacidosis and methods of risk management and
provided with appropriate tools for accurate ketone measurement (i.e., serum β-
hydroxybutyrate). E
224

225

226

227

Section 11.
Chronic Kidney Disease and Risk Management

Chronic Kidney Disease - Screening
11.1a Assess kidney function (i.e., spot urine albumin-to-creatinine ratio [UACR]) and
estimated glomerular filtration rate [eGFR] in people with type 1 diabetes with duration of ≥5
years and in all people with type 2 diabetes regardless of treatment. B
11.1b In people with established chronic kidney disease (CKD), monitor urinary albumin
(e.g., spot UACR) and eGFR 1–4 times per year depending on the stage of the kidney
disease (Fig. 11.1). B
229

Chronic Kidney Disease - Treatment
11.2 Optimize glucose management to reduce the risk or slow the progression of CKD (Fig.
9.3). A
11.3 Optimize blood pressure management (aim for <130/80 mmHg [Fig. 10.2]) and reduce
blood pressure variability to reduce the risk or slow the progression of CKD and reduce
cardiovascular risk. A
11.4a In nonpregnant people with diabetes and hypertension, either an ACE inhibitor or an
angiotensin receptor blocker (ARB) is recommended for those with moderately increased
albuminuria (UACR 30–299 mg/g creatinine) B and is strongly recommended for those with
severely increased albuminuria (UACR ≥300 mg/g creatinine) and/or eGFR <60
mL/min/1.73 m2
to maximally tolerated dose to prevent the progression of kidney disease
and reduce cardiovascular events. A
11.4b Monitor for increased serum creatinine and for increased serum potassium levels
when ACE inhibitors, ARBs, and mineralocorticoid receptor antagonists (MRAs) are used,
or for hypokalemia when diuretics are used at routine visits and 7–14 days after initiation or
after a dose change. B 230

Chronic Kidney Disease – Treatment
(continued)
11.4c An ACE inhibitor or an ARB is not recommended for the primary prevention of CKD in
people with diabetes who have normal blood pressure, normal UACR (<30 mg/g
creatinine), and normal eGFR. A
11.4d Continue renin-angiotensin system blockade for mild to moderate increases in serum
creatinine (≤30%) in individuals who have no signs of extracellular fluid volume depletion. A
11.5a For people with type 2 diabetes and CKD, use of a sodium-glucose cotransporter 2
(SGLT2) inhibitor with demonstrated benefit is recommended to reduce CKD progression
and cardiovascular events in individuals with eGFR ≥20 mL/min/1.73m2
. A
11.5b To reduce cardiovascular risk and kidney disease progression in people with type 2
diabetes and CKD, a glucagon-like peptide 1 agonist with demonstrated benefit in this
population is recommended. A
231

(continued)
11.5c To reduce cardiovascular events and CKD progression in people with CKD and
albuminuria, a nonsteroidal MRA that has been shown to be effective in clinical trials is
recommended (if eGFR is ≥25 mL/min/1.73 m2
). Potassium levels should be monitored. A
11.6 Potentially harmful antihypertensive medications in pregnancy should be avoided in
sexually active individuals of childbearing potential who are not using reliable contraception
and, if used, should be switched prior to conception to antihypertensive medications
considered safer during pregnancy. B
11.7 Aim to reduce urinary albumin by ≥30% in people with CKD and albuminuria ≥300
mg/g to slow CKD progression. B
11.8 For people with non-dialysis-dependent stage G3 or higher CKD, protein intake should
be 0.8 g/kg body weight per day, as for the general population. A For individuals on dialysis,
protein intake of 1.0–1.2 g/kg/day should be considered since protein energy wasting is a
major problem for some individuals on dialysis. B
232

(continued)
11.9 Individuals should be referred for evaluation by a nephrologist if they have
continuously increasing urinary albumin levels and/or continuously decreasing eGFR and/or
if the eGFR is <30 mL/min/1.73 m2
. A
11.10 Refer to a nephrologist for uncertainty about the etiology of kidney disease, difficult
management issues, and rapidly progressing kidney disease. B
233

234
Chronic Kidney Disease and Risk Management:

235

236

237

238

239

Section 12.
Retinopathy, Neuropathy, and Foot Care

Diabetic Retinopathy
12.1 Implement strategies to help people with diabetes reach glycemic goals to reduce the
risk or slow the progression of diabetic retinopathy. A
12.2 Implement strategies to help people with diabetes reach blood pressure and lipid goals
to reduce the risk or slow the progression of diabetic retinopathy. A
241

Diabetic Retinopathy - Screening
12.3 Adults with type 1 diabetes should have an initial dilated and comprehensive eye
examination by an ophthalmologist or optometrist within 5 years after the onset of diabetes.
B
12.4 People with type 2 diabetes should have an initial dilated and comprehensive eye
examination by an ophthalmologist or optometrist at the time of the diabetes diagnosis. B
12.5 If there is no evidence of retinopathy from one or more annual eye exams and
glycemic indicators are within the goal range, then screening every 1–2 years may be
considered. If any level of diabetic retinopathy is present, subsequent dilated retinal
examinations should be repeated at least annually by an ophthalmologist or optometrist. If
retinopathy is progressing or sight-threatening, then examinations by an ophthalmologist
will be required more frequently. B
242

Diabetic Retinopathy – Screening
(continued)
12.6 Programs that use retinal photography with remote reading or the use of U.S. Food
and Drug Administration-approved artificial intelligence algorithms to improve access to
diabetic retinopathy screening are appropriate screening strategies for diabetic retinopathy.
Such programs need to provide pathways for timely referral for a comprehensive eye
examination when indicated. B
12.7 Counsel individuals of childbearing potential with preexisting type 1 or type 2 diabetes
who are planning pregnancy or who are pregnant on the risk of development and/or
progression of diabetic retinopathy. B
12.8 Individuals with preexisting type 1 or type 2 diabetes should receive an eye exam
before pregnancy as well as in the first trimester and may need to be monitored every
trimester and for 1 year postpartum as indicated by the degree of retinopathy. B
243

Diabetic Retinopathy – Treatment
12.9 Promptly refer individuals with any level of diabetic macular edema, moderate or
worse nonproliferative diabetic retinopathy (a precursor of proliferative diabetic retinopathy
[PDR]), or any PDR to an ophthalmologist who is knowledgeable and experienced in the
management of diabetic retinopathy. A
12.10 Panretinal laser photocoagulation therapy is indicated to reduce the risk of vision loss
in individuals with high-risk PDR and, in some cases, severe nonproliferative diabetic
retinopathy. A
12.11 Intravitreous injections of anti-vascular endothelial growth factor (anti-VEGF) are a
reasonable alternative to traditional panretinal laser photocoagulation for some individuals
with PDR and also reduce the risk of vision loss in these individuals. A
244

Diabetic Retinopathy – Treatment
(continued)
12.12 Intravitreous injections of anti-VEGF are indicated as first-line treatment for most
eyes with diabetic macular edema that involves the foveal center and impairs vision acuity.
A
12.13 Macular focal/grid photocoagulation and intravitreal injections of corticosteroid are
reasonable treatments in eyes with persistent diabetic macular edema despite previous
anti-VEGF therapy or eyes that are not candidates for this first-line approach. A
12.14 The presence of retinopathy is not a contraindication to aspirin therapy for
cardioprotection, as aspirin does not increase the risk of retinal hemorrhage. A
245

Visual Rehabilitation
12.15 People who experience vision loss from diabetes should be counseled on the
availability and scope of vision rehabilitation care and provided, or referred for, a
comprehensive evaluation of their visual impairment by a practitioner experienced in vision
rehabilitation. E
12.16 People with vision loss from diabetes should receive educational materials and
resources for eye care support in addition to self-management education (e.g., glycemic
management and hypoglycemia awareness). E
246

Neuropathy
12.17 All people with diabetes should be assessed for diabetic peripheral neuropathy
starting at diagnosis of type 2 diabetes and 5 years after the diagnosis of type 1 diabetes
and at least annually thereafter. B
12.18 Assessment for distal symmetric polyneuropathy should include a careful history and
assessment of either temperature or pinprick sensation (small-fiber function) and vibration
sensation using a 128-Hz tuning fork (for large-fiber function). All people with diabetes
should have annual 10-g monofilament testing to identify feet at risk for ulceration and
amputation. B
12.19 Symptoms and signs of autonomic neuropathy should be assessed in people with
diabetes starting at diagnosis of type 2 diabetes and 5 years after the diagnosis of type 1
diabetes, and at least annually thereafter, and with evidence of other microvascular
complications, particularly kidney disease and diabetic peripheral neuropathy. Screening
can include asking about orthostatic dizziness, syncope, early satiety, erectile dysfunction,
changes in sweating patterns, or dry cracked skin in the extremities. Signs of autonomic
neuropathy include orthostatic hypotension, a resting tachycardia, or evidence of peripheral
dryness or cracking of skin. E 247

Neuropathy – Treatment
12.20 Optimize glucose management to prevent or delay the development of neuropathy in
people with type 1 diabetes A and to slow the progression of neuropathy in people with type
2 diabetes. C Optimize weight, blood pressure, and serum lipid management to reduce the
risk or slow the progression of diabetic neuropathy. B
12.21 Assess and treat pain related to diabetic peripheral neuropathy B and symptoms of
autonomic neuropathy to improve quality of life. E
12.22 Gabapentinoids, serotoninnorepinephrine reuptake inhibitors, tricyclic
antidepressants, and sodium channel blockers are recommended as initial pharmacologic
treatments for neuropathic pain in diabetes. A Opioids, including tramadol and tapentadol,
should not be used for neuropathic pain treatment in diabetes given the potential for
adverse events. B
248

Foot Care
12.23 Perform a comprehensive foot evaluation at least annually to identify risk factors for
ulcers and amputations. A
12.24 The examination should include inspection of the skin, assessment of foot
deformities, neurological assessment (10-g monofilament testing or Ipswich touch test with
at least one additional assessment: pinprick, temperature, or vibration), and vascular
assessment, including pulses in the legs and feet. B
12.25 Individuals with evidence of sensory loss or prior ulceration or amputation should
have their feet inspected at every visit. A
12.26 Obtain a prior history of ulceration, amputation, Charcot foot, angioplasty or vascular
surgery, cigarette smoking, retinopathy, and renal disease and assess current symptoms of
neuropathy (pain, burning, numbness) and vascular disease (leg fatigue, claudication). B
249

Foot Care (continued)
12.27 Initial screening for peripheral arterial disease (PAD) should include assessment of
lower-extremity pulses, capillary refill time, rubor on dependency, pallor on elevation, and
venous filling time. Individuals with a history of leg fatigue, claudication, and rest pain
relieved with dependency or decreased or absent pedal pulses should be referred for
ankle-brachial index with toe pressures and for further vascular assessment as appropriate.
B
12.28 An interprofessional approach facilitated by a podiatrist in conjunction with other
appropriate team members is recommended for individuals with foot ulcers and high-risk
feet (e.g., those on dialysis, those with Charcot foot, those with a history of prior ulcers or
amputation, and those with PAD). B
12.29 Refer individuals who smoke and have a history of prior lower-extremity
complications, loss of protective sensation, structural abnormalities, or PAD to foot care
specialists for ongoing preventive care and lifelong surveillance. B These individuals should
also be provided with information on the importance of smoke cessation and referred for
counseling on smoke cessation. A
250

Foot Care (continued)
12.30 Provide general preventive foot self-care education to all people with diabetes,
including those with loss of protective sensation, on appropriate ways to examine their feet
(palpation or visual inspection with an unbreakable mirror) for daily surveillance of early foot
problems. B
12.31 The use of specialized therapeutic footwear is recommended for people with diabetes
at high risk for ulceration, including those with loss of protective sensation, foot deformities,
ulcers, callous formation, poor peripheral circulation, or history of amputation. B
12.32 For chronic diabetic foot ulcers that have failed to heal with optimal standard care
alone, adjunctive treatment with randomized controlled trial-proven advanced agents
should be considered. Considerations might include negative-pressure wound therapy,
placental membranes, bioengineered skin substitutes, several acellular matrices,
autologous fibrin and leukocyte platelet patches, and topical oxygen therapy. A
251

Factors that are associated with the at-risk
foot include the following:
 Poor glycemic management
 Peripheral neuropathy/LOPS
 PAD
 Foot deformities (bunions, hammertoes, Charcot joint, etc.)
 Preulcerative corns or calluses
 Prior ulceration
 Prior amputation
 Smoking
 Retinopathy
 Nephropathy (particularly individuals on dialysis or posttransplant)
252

253
Retinopathy, Neuropathy, and Foot Care:

254
Retinopathy, Neuropathy, and Foot Care:

Section 13.
Older Adults

Overall recommendations
256
13. Older Adults
13.1 Assess the medical, psychological, functional (self-management abilities), and social
domains in older adults with diabetes to provide a framework to determine goals and
therapeutic approaches for diabetes management. B
13.2 Screen at least annually for geriatric syndromes (e.g., cognitive impairment,
depression, urinary incontinence, falls, persistent pain, and frailty), hypoglycemia, and
polypharmacy in older adults with diabetes, as they may affect diabetes management and
diminish quality of life. B

257
13. Older Adults
Older Adults:

Neurocognitive Function
258
13. Older Adults
13.3 Screening for early detection of mild cognitive impairment or dementia should be
performed for adults 65 years of age or older at the initial visit, annually, and as appropriate.
B

Hypoglycemia
259
13. Older Adults
13.4 Ascertain and address episodes of hypoglycemia at routine visits because older adults
with diabetes have a greater risk of hypoglycemia, especially when treated with
hypoglycemic agents (e.g., sulfonylureas, meglitinides, and insulin). B
13.5 Recommend continuous glucose monitoring (CGM) for older adults with type 1
diabetes to improve glycemic outcomes, reduce hypoglycemia, and reduce treatment
burden. A
13.6 Offer CGM for older adults with type 2 diabetes on insulin therapy to improve glycemic
outcomes and reduce hypoglycemia. B
13.7 Consider the use of automated insulin delivery systems, A mechanical insulin delivery
systems, E and other advanced insulin delivery devices such as connected pens E to
reduce risk of hypoglycemia for older adults, based on individual ability and support system.

Treatment Goals
260
13. Older Adults
13.8a Older adults with diabetes who are otherwise healthy with few and stable coexisting
chronic illnesses and intact cognitive and functional status should have lower glycemic
goals (such as A1C <7.0–7.5% [<53–58 mmol/mol]) and/or time in range [TIR] 70–180
mg/dL [3.9-10.0 mmol] of 70% and time below range ≤70 mg/dL [3.9 mmol/L] of ≤4%) if
CGM is used. C
13.8b Older adults with diabetes and intermediate or complex health are clinically
heterogeneous with variable life expectancy. Selection of glycemic goals should be
individualized and should prioritize avoidance of hypoglycemia, with less stringent goals
(such as A1C <8.0% [<64 mmol/mol] and/or TIR 70-180 mg/dL [3.9-10.0 mmol] of 50% and
time below range <70 mg/dL [3.9 mmol/L] of <1%) for those with significant cognitive and/or
functional limitations, frailty, severe comorbidities, and a less favorable risk-to-benefit ratio
of diabetes medications. C
13.8c Older adults with very complex or poor health receive minimal benefit from stringent
glycemic goals. Clinicians should focus on avoiding hypoglycemia and symptomatic
hyperglycemia rather than achieving stringent glycemic goals. C

Treatment Goals (continued)
261
13. Older Adults
13.9 Screening for diabetes complications should be individualized in older adults with
diabetes. Particular attention should be paid to complications that would lead to impairment
of functional status or quality of life. C
13.10 Treatment of hypertension to individualized goal levels is indicated in most older
adults with diabetes. B
13.11 Treatment of other cardiovascular risk factors should be individualized in older adults
with diabetes, considering the time frame of benefit. Lipid-lowering therapy and antiplatelet
agents may benefit those with life expectancies at least equal to the time frame of primary
prevention or secondary intervention trials. E

262
13. Older Adults
Older Adults:

263
13. Older Adults
Older Adults:

Lifestyle Management
264
13. Older Adults
13.12 Recommend healthful eating with adequate protein intake for older adults with
diabetes. Recommend regular exercise, including aerobic activity, weight-bearing exercise,
and/or resistance training as tolerated in those who can safely engage in such activities. B
13.13 For older adults with type 2 diabetes, overweight or obesity, and capacity to exercise
safely, an intensive lifestyle intervention focused on dietary changes, physical activity, and
modest weight loss (e.g., 5–7%) should be considered for its benefits on quality of life,
mobility and physical functioning, and cardiometabolic risk. A

Pharmacologic Therapy
265
13. Older Adults
13.14 Select medications with low risk of hypoglycemia in older adults with type 2 diabetes,
specifically for those with hypoglycemia risk factors. B
13.15 Overtreatment of diabetes is common in older adults and should be avoided. B
13.16a Deintensify hypoglycemia-causing medications (e.g., insulin, sulfonylureas, or
meglitinides) or switch to a medication class with low hypoglycemia risk for individuals who
are at high risk for hypoglycemia, using individualized glycemic goals. B
13.16b In older adults with diabetes, deintensify diabetes medications for individuals for
whom the harms and/or burdens of treatment may be greater than the benefits, within
individualized glycemic goals. E

Pharmacologic Therapy (continued)
266
13. Older Adults
13.16c Simplify complex treatment plans (especially insulin) to reduce the risk of
hypoglycemia and polypharmacy and decrease the treatment burden if it can be achieved
within the individualized glycemic goals. B
13.16d In older adults with type 2 diabetes and established or high risk of atherosclerotic
cardiovascular disease, heart failure, and/or chronic kidney disease, the treatment plan
should include agents that reduce cardiovascular and kidney disease risk, irrespective of
glycemia. A
13.17 Consider costs of care and coverage when developing treatment plans in order to
reduce risk of cost-related barriers to medication taking and self-management behaviors. B

267
13. Older Adults
Older Adults:

268
13. Older Adults
Older Adults:

269
13. Older Adults
Older Adults:

270
13. Older Adults
Older Adults:

Treatment in Post-Acute and Long-Term
Care Settings
271
13. Older Adults
13.18 Recommend diabetes education/training (including that for CGM devices, insulin
pumps, and advanced insulin delivery systems) for the staff of long-term care and
rehabilitation facilities to improve the management of older adults with diabetes. E
13.19 People with diabetes residing in long-term care facilities need careful assessment of
mobility, mentation, medications, and management preferences to establish individualized
glycemic goals and to make appropriate choices of glucose-lowering agents and devices
(including CGM devices, insulin pumps, and advanced insulin delivery systems) based on
their clinical and functional status. E See Fig. 13.1 for the 4Ms framework to address
person-specific issues that affect diabetes management in older individuals.

272
13. Older Adults
For hypoglycemia, the following alert strategy could be considered:
1. Call a health care professional immediately in cases of low blood glucose levels (<70
mg/dL [<3.9 mmol/L]). However, treatment of hypoglycemia should not be delayed.
2. Call as soon as possible when
a) glucose values are 70–100 mg/dL (3.9–5.6 mmol/L) (treatment plan may need to be
adjusted),
b) two or more blood glucose values >250 mg/dL (>13.9 mmol/L) are observed within a
24-h period accompanied by a significant change in clinical status,
c) glucose values are consistently >250 mg/dL (>13.9 mmol/L) within a 24-h period,
d) glucose values are consistently >300 mg/dL (>16.7 mmol/L) over 2 consecutive
days,
e) any reading is too high for the glucose monitoring device, or
f) the individual is sick, with symptomatic hyperglycemia, vomiting, fever, lethargy, or
poor oral intake.

End-of-Life Care
273
13. Older Adults
13.20 When palliative care is needed in older adults with diabetes, health care
professionals should initiate conversations with people with diabetes and their care partners
regarding the goals and intensity of care. Strict glucose and blood pressure management
are not necessary, and simplification of medication plans can be considered. Similarly, the
intensity of lipid management can be relaxed, and withdrawal of lipid-lowering therapy may
be appropriate. E
13.21 Prioritize the overall comfort, prevention of distressing symptoms, and preservation of
quality of life and dignity as primary goals for diabetes management at the end of life. C

274
13. Older Adults
Different categories have been proposed for diabetes management in those with advanced
disease:
1. A stable individual: Continue with the person’s previous medication plan, with a focus on 1) the
prevention of hypoglycemia and 2) the management of hyperglycemia using blood glucose
monitoring, keeping levels below the renal threshold of glucose, and hyperglycemia-mediated
dehydration. There is no role for A1C monitoring.
2. An individual with organ failure: Preventing hypoglycemia is of greatest significance.
Dehydration must be prevented and treated. In people with type 1 diabetes, insulin administration
may be reduced as the oral intake of food decreases but should not be stopped. For those with
type 2 diabetes, agents that may cause hypoglycemia should be reduced in dose. The main goal
is to avoid hypoglycemia, allowing for glucose values in the upper level of the desired goal range.
3. A dying individual: For people with type 2 diabetes, the discontinuation of all medications may
be a reasonable approach, as these individuals are unlikely to have any oral intake. In people
with type 1 diabetes, there is no consensus, but a small amount of basal insulin may maintain
glucose levels and prevent acute hyperglycemic complications and symptom burden.

Section 14.
Children and Adolescents

276
Children and Adolescents:

277
Table 14.1A (continued)

278

279
Table 14.1B (continued)

Support (Type 1)
14.1 Youth with type 1 diabetes and their parents or caregivers (for individuals aged <18
years) should receive culturally sensitive and developmentally appropriate individualized
diabetes self-management education and support (DSMES) according to national
standards at diagnosis and routinely thereafter. B
280

Nutrition Therapy (Type 1)
14.2 Individualized medical nutrition therapy (MNT) is recommended for youth with type 1
diabetes as an essential component of the overall treatment plan. A
14.3 Monitoring carbohydrate intake, whether by carbohydrate counting or experience-
based estimation, is a key component to optimizing glycemic management. B
14.4 Advise youth with type 1 diabetes and their caregivers to strive for an eating pattern
emphasizing key nutrition principles (including nonstarchy vegetables, whole fruits,
legumes, fish and other lean protein, whole grains, nuts and seeds, and low-fat dairy
products, and minimize consumption of red meat, sugar-sweetened beverages, sweets,
refined grains, and processed foods). B
14.5 Meal composition impacts postprandial glucose excursions. Education on the impact
of high-fat and high-protein meals and the adjustment of insulin dosing is necessary. A
14.6 Strongly advise comprehensive nutrition education at diagnosis, and at least annually
as needed, by an experienced registered dietitian nutritionist to assess the eating pattern in
relation to weight status, age-appropriate growth, and cardiovascular disease risk factors. E
281

Physical Activity and Exercise (Type 1)
14.7 Physical activity is recommended for all youth with type 1 diabetes with the goal of 60
min of moderate- to vigorous-intensity aerobic activity daily, with vigorous muscle-
strengthening and bone-strengthening activities at least 3 days per week. C
14.8 Advise frequent glucose monitoring before, during, and after exercise, via blood
glucose meter and/or continuous glucose monitoring (CGM), to prevent, detect, and treat
hypoglycemia and hyperglycemia associated with exercise. C
14.9 Youth and their parents or caregivers should receive education on goals and
management of glycemia before, during, and after physical activity, individualized according
to the type and intensity of the planned physical activity. C
14.10 Youth and their parents or caregivers should be educated on strategies to prevent
hypoglycemia during, after, and overnight following physical activity and exercise.
Treatment for hypoglycemia should be accessible before, during, and after engaging in
activity. C
282

Psychosocial Care (Type 1)
14.11 At diagnosis and during routine follow-up care, screen youth with type 1 diabetes for
psychosocial concerns (e.g., diabetes distress, depressive symptoms, and disordered
eating), family factors, and behavioral health concerns that could impact diabetes
management with age-appropriate standardized and validated tools. Refer to a qualified
behavioral health professional, preferably experienced in childhood diabetes, when
indicated. B
14.12 Behavioral health professionals should be considered integral members of the
pediatric diabetes interprofessional team. E
14.13 Encourage developmentally appropriate family involvement in diabetes management
tasks for children and adolescents, recognizing that premature or unsupportive transfer of
diabetes care responsibility to the youth can contribute to diabetes distress, lower
engagement in diabetes self-management behaviors, and deterioration in glycemia. A
283

Psychosocial Care (Type 1, continued)
14.14 Health care professionals should screen for food security, housing stability, health
literacy, financial barriers, and social or community support and apply that information to
treatment decisions. E
14.15 Health care professionals should consider asking youth and their parents or
caregivers about social adjustment (peer relationships) and school performance to
determine whether further intervention is needed. B
14.16 Offer adolescents time by themselves with their health care professional(s) at a
developmentally appropriate age. E
14.17 Starting at puberty, preconception counseling should be incorporated into routine
diabetes care for all individuals of childbearing potential. A
284

Glycemic Monitoring, Insulin Delivery, and
Goals (Type 1)
14.18 All youth with type 1 diabetes should monitor glucose levels multiple times daily (up
to 10 times/day by blood glucose meter or CGM), including prior to meals and snacks, at
bedtime, and as needed for safety in specific situations such as physical activity, driving, or
the presence of symptoms of hypoglycemia. B
14.19 Real-time CGM A or intermittently scanned CGM C should be offered for diabetes
management at diagnosis or as soon as possible in youth with diabetes on multiple daily
injections or insulin pump therapy who are capable of using the device safely (either by
themselves or with caregivers). The choice of device should be made based on the
individual’s and family’s circumstances, desires, and needs.
14.20 Automated insulin delivery (AID) systems should be offered for diabetes
management to youth with type 1 diabetes who are capable of using the device safely
(either by themselves or with caregivers). The choice of device should be made based on
the individual’s and family’s circumstances, desires, and needs. A
285

Goals (Type 1, continued)
14.21 Insulin pump therapy alone should be offered for diabetes management to youth on
multiple daily injections with type 1 diabetes who are capable of using the device safely
(either by themselves or with caregivers) if unable to use AID systems. The choice of device
should be made based on the individual’s and family’s circumstances, desires, and needs.
A
14.22 Students must be supported at school in the use of diabetes technology, including
CGM, insulin pumps, connected insulin pens, and AID systems, as prescribed by their
diabetes care team. E
14.23 A1C goals must be individualized and reassessed over time. An A1C of <7% (<53
mmol/mol) is appropriate for many children and adolescents. B
14.24 Less stringent A1C goals (such as <7.5% [<58 mmol/mol]) may be appropriate for
youth who cannot articulate symptoms of hypoglycemia; have hypoglycemia unawareness;
lack advanced insulin delivery technology and/or CGM; cannot check blood glucose
regularly; or have nonglycemic factors that increase A1C (e.g., high glycators). B
286

Goals (Type 1, continued)
14.25 Even less stringent A1C goals (such as <8% [<64 mmol/mol]) may be appropriate for
individuals with a history of severe hypoglycemia or limited life expectancy or where the
harms of treatment are greater than the benefits. B
14.26 Health care professionals may reasonably suggest more stringent A1C goals (such
as <6.5% [<48 mmol/mol]) for selected individuals if they can be achieved without
significant hypoglycemia, excessive weight gain, negative impacts on well-being, or undue
burden of care or in those who have nonglycemic factors that decrease A1C (e.g., lower
erythrocyte life span). Lower goals may also be appropriate during the honeymoon phase.
B
14.27 CGM metrics derived from CGM use over the most recent 14 days (or longer for
youth with more glycemic variability), including time in range (70–180 mg/dL [3.9–10.0
mmol/L]), time below range (<70 mg/dL [<3.9 mmol/L] and <54 mg/dL [<3.0 mmol/L]), and
time above range (>180 mg/dL [>10.0 mmol/L] and >250 mg/dL [>13.9 mmol/L]), are
recommended to be used in conjunction with A1C whenever possible. E
287

Autoimmune Conditions (Type 1)
14.28 Assess for additional autoimmune conditions soon after the diagnosis of type 1
diabetes and if clinically relevant. B
288

Thyroid Disease (Type 1)
14.29 Consider testing children with type 1 diabetes for antithyroid peroxidase and
antithyroglobulin antibodies soon after diagnosis. B
14.30 Measure thyroid-stimulating hormone concentrations at diagnosis when clinically
stable or soon after optimizing glycemia. If normal, suggest rechecking every 1–2 years or
sooner if the youth has positive thyroid antibodies or develops symptoms or signs
suggestive of thyroid dysfunction, thyromegaly, an abnormal growth rate, or unexplained
glycemic variability. B
289

Celiac Disease (Type 1)
14.31 Screen youth with type 1 diabetes for celiac disease by measuring IgA tissue
transglutaminase (tTG) antibodies, with documentation of normal total serum IgA levels,
soon after the diagnosis of diabetes, or IgG tTG and deamidated gliadin antibodies if IgA is
deficient. B
14.32 Repeat screening for celiac disease within 2 years of diabetes diagnosis and then
again after 5 years and consider more frequent screening in youth who have symptoms or
a first-degree relative with celiac disease. B
14.33 Individuals with confirmed celiac disease should be placed on a gluten-free diet for
treatment and to avoid complications. Youth and their caregivers should also have a
consultation with a registered dietitian nutritionist experienced in managing both diabetes
and celiac disease. B
290

Management of Cardiovascular Risk
Factors – Hypertension Screening (Type 1)
14.34 Blood pressure should be measured at every routine visit. In youth with high blood
pressure (blood pressure ≥90th percentile for age, sex, and height or, in adolescents aged
≥13 years, blood pressure ≥120/80 mmHg) on three separate measurements, ambulatory
blood pressure monitoring should be strongly considered. B
291

Factors – Hypertension Treatment (Type 1)
14.35 Treatment of elevated blood pressure (defined as 90th to <95th percentile for age,
sex, and height or, in adolescents aged ≥13 years, 120–129/<80 mmHg) is lifestyle
modification focused on healthy nutrition, physical activity, sleep, and, if appropriate, weight
management. C
14.36 After excluding other causes, in addition to lifestyle modification, ACE inhibitors or
angiotensin receptor blockers should be started for treatment of confirmed hypertension
(defined as blood pressure consistently ≥95th percentile for age, sex, and height or, in
adolescents aged ≥13 years, ≥130/80 mmHg). Due to the potential teratogenic effects,
individuals of childbearing age should receive reproductive counseling, and ACE inhibitors
and angiotensin receptor blockers should be avoided in individuals of childbearing age who
are not using reliable contraception. B
14.37 The goal of treatment is blood pressure <90th percentile for age, sex, and height or,
in adolescents aged ≥13 years, <130/80 mmHg. C
292

Factors – Dyslipidemia Screening (Type 1)
14.38 Initial lipid profile should be performed soon after diagnosis, preferably after glycemia
has improved and age is ≥2 years. If initial LDL cholesterol is ≤100 mg/dL (≤2.6 mmol/L),
subsequent testing should be performed at 9–11 years of age. B Initial testing may be done
with a nonfasting lipid level with confirmatory testing with a fasting lipid panel.
14.39 If LDL cholesterol values are within the accepted risk level (<100 mg/dL[<2.6
mmol/L]), a lipid profile repeated every 3 years is reasonable. E
293

Factors – Dyslipidemia Treatment (Type 1)
14.40 If lipids are abnormal, initial therapy should consist of optimizing glycemia and MNT
to limit the amount of calories from fat to 25–30% and saturated fat to <7%, limit cholesterol
to <200 mg/day, avoid trans fats, and aim for ~10% calories from monounsaturated fats. A
14.41 Consider age-approved statins, in addition to MNT and lifestyle changes, for youth
with type 1 diabetes who have LDL cholesterol ≥130 mg/dL (≥3.4 mmol/L). E Individuals of
childbearing age should receive reproductive counseling, and lipid-lowering medications
should be avoided in most individuals of childbearing age who are not using reliable
contraception. B
14.42 The goal of therapy is an LDL cholesterol value <100 mg/dL (<2.6 mmol/L). E
294

Microvascular Complications –
Nephropathy Screening (Type 1)
14.43 Annual screening for albuminuria with a random (morning sample preferred to avoid
effects of exercise) spot urine sample for albumin-to-creatinine ratio should be considered
at puberty or at age >10 years, whichever is earlier, once the youth has had diabetes for 5
years. B
295

Nephropathy Treatment (Type 1)
14.44 An ACE inhibitor or an angiotensin receptor blocker, titrated to normalization of
albumin excretion, may be considered when elevated urinary albumin-to-creatinine ratio
(>30 mg/g) is documented (two of three urine samples obtained over a 6-month interval
following efforts to improve glycemia and normalize blood pressure). E Due to the potential
teratogenic effects, individuals of childbearing age should receive reproductive counseling,
and ACE inhibitors and angiotensin receptor blockers should be avoided in individuals of
childbearing age who are not using reliable contraception. B
296

Retinopathy (Type 1)
14.45 An initial dilated and comprehensive eye examination is recommended once youth
have had type 1 diabetes for 3–5 years, provided they are aged ≥11 years or puberty has
started, whichever is earlier. B
14.46 After the initial examination, repeat dilated and comprehensive eye examination
every 2 years. Less frequent examinations, every 4 years, may be acceptable on the advice
of an eye care professional and based on risk factor assessment, including a history of
A1C<8% (<64 mmol/mol). B
14.47 Programs that use retinal photography (with remote reading or use of a validated
assessment tool) to improve access to diabetic retinopathy screening can be appropriate
screening strategies for diabetic retinopathy. Such programs need to provide pathways for
timely referral for a comprehensive eye examination when indicated. B
297

Neuropathy (Type 1)
14.48 Consider an annual comprehensive foot exam at the start of puberty or at age ≥10
years, whichever is earlier, once the youth has had type 1 diabetes for 5 years. The
examination should include inspection, assessment of foot pulses, pinprick, and 10-g
monofilament sensation tests, testing of vibration sensation using a 128-Hz tuning fork, and
ankle reflex tests. B
298

Screening and Diagnosis (Type 2)
14.49 Risk-based screening for prediabetes and/or type 2 diabetes should be considered
after the onset of puberty or ≥10 years of age, whichever occurs earlier, in youth with
overweight (BMI ≥85th percentile) or obesity (BMI ≥95th percentile) and who have one or
more additional risk factors for diabetes (see Table 2.5 for evidence grading of other risk
factors).
14.50 If screening is normal, repeat screening at a minimum of 2-year intervals E or more
frequently if BMI is increasing. C
14.51 Fasting plasma glucose, 2-h plasma glucose during a 75-g oral glucose tolerance
test, and A1C can be used to test for prediabetes or diabetes in children and adolescents. B
14.52 Children and adolescents with overweight or obesity in whom the diagnosis of type 2
diabetes is being considered should have a panel of pancreatic autoantibodies tested to
exclude the possibility of autoimmune type 1 diabetes. B
299

Management – Lifestyle (Type 2)
14.53 All youth with type 2 diabetes and their families should receive comprehensive DSMES that is
specific to youth with type 2 diabetes and is culturally appropriate. B
14.54 Youth with overweight or obesity and type 2 diabetes and their families should be provided with
developmentally and culturally appropriate comprehensive lifestyle programs that are integrated with
diabetes management to achieve at least a 7–10% decrease in excess weight. B
14.55 Given the necessity of long-term weight management for youth with type 2 diabetes, lifestyle
intervention should be based on a chronic care model and offered in the context of diabetes care. E
14.56 Youth with prediabetes and type 2 diabetes, like all children and adolescents, should be
encouraged to participate in at least 60 min of moderate to vigorous physical activity daily (with
muscle and bone strength training at least t days/week) B and to decrease sedentary recreational
screen time. C
14.57 Nutrition for youth with prediabetes and type 2 diabetes, like for all children and adolescents,
should focus on key nutrition principles (i.e., eat more nonstarchy vegetables, whole fruits, legumes,
whole grains, nuts and seeds, and low-fat dairy products and eat less meat, sugar-sweetened
beverages, sweets, refined grains, and processed or ultraprocessed foods). B
300

Management – Glycemic Goals (Type 2)
14.58 Real-time CGM or intermittently scanned CGM should be offered for diabetes
management in youth with type 2 diabetes on multiple daily injections or insulin pumps who
are capable of using the device safely (either by themselves or with a caregiver). The
choice of device should be made based on an individual’s and family’s circumstances,
desires, and needs. E
14.59 Glycemic status should be assessed at least every 3 months. E
14.60 Consider setting an A1C goal of <6.5% (<48 mmol/mol) for most children and
adolescents with type 2 diabetes who have a low risk of hypoglycemia. For those at higher
risk of hypoglycemia, A1C goals should be individualized as clinically appropriate. C
301

Pharmacologic Management (Type 2)
14.61 Initiate pharmacologic therapy, in addition to behavioral counseling for healthful
nutrition and physical activity changes, at diagnosis of type 2 diabetes. A
14.62 In individuals with incidentally diagnosed or metabolically stable diabetes (A1C
<8.5% [<69 mmol/mol] and asymptomatic), metformin is the initial pharmacologic treatment
of choice if kidney function is normal. A
14.63 Youth with marked hyperglycemia (blood glucose ≥250 mg/dL [≥13.9 mmol/L], A1C
≥8.5% [≥69 mmol/mol]) without acidosis at diagnosis who are symptomatic with polyuria,
polydipsia, nocturia, and/or weight loss should be treated initially with long-acting insulin
while metformin is initiated and titrated. B
14.64 Initiate subcutaneous or intravenous insulin treatment in individuals with ketoacidosis
to rapidly correct the hyperglycemia and the metabolic derangement. Once acidosis is
resolved, metformin should be initiated while subcutaneous insulin therapy is continued. A
302

Pharmacologic Management (Type 2)
14.65 In individuals presenting with severe hyperglycemia (blood glucose ≥600 mg/dL
[≥33.3 mmol/L]), consider assessment for hyperglycemic hyperosmolar state. A
14.66 If glycemic goals are no longer met with metformin (with or without long-acting
insulin), glucagon-like peptide 1 (GLP-1) receptor agonist therapy and/or empagliflozin
should be considered in children 10 years of age or older. A
14.67 When choosing glucose-lowering or other medications for youth with overweight or
obesity and type 2 diabetes, consider medication-taking behavior and the medications’
effect on weight. E
14.68 For youth not meeting glycemic goals, consider maximizing noninsulin therapies
(metformin, a GLP-1 receptor agonist, and empagliflozin) before initiating and/or
intensifying the insulin therapy plan. E
14.69 In individuals initially treated with insulin and metformin and/or other glucose-lowering
medications who are meeting glucose goals based on blood glucose monitoring or CGM,
insulin can be tapered over 2–6 weeks by decreasing the insulin dose 10–30% every few
days. B 303

304

305

Metabolic Surgery (Type 2)
14.70 Metabolic surgery may be considered for the treatment of adolescents with type 2
diabetes who have class 2 obesity or higher (BMI >35 kg/m2
or >120% of 95th percentile for
age and sex, whichever is lower) and who have elevated A1C and/or serious comorbidities
despite lifestyle and pharmacologic intervention. A
14.71 Metabolic surgery should be performed only by an experienced surgeon working as
part of a well-organized and engaged interprofessional team, including a surgeon,
endocrinologist, registered dietitian nutritionist, behavioral health specialist, and nurse. A
306

Prevention and Management of Diabetes
Complications – Hypertension (Type 2)
14.72 Blood pressure should be measured at every clinic visit. In youth with high blood
pressure (blood pressure ≥90th percentile for age, sex, and height or, in adolescents aged ≥13
years, ≥120/80 mmHg) on three separate measurements, ambulatory blood pressure
monitoring should be strongly considered. B
14.73 After excluding secondary hypertension, treatment of elevated blood pressure (defined as
90th to <95th percentile for age, sex, and height or, in adolescents aged ≥13 years,
120–129/<80 mmHg) is lifestyle modification focused on healthy nutrition, physical activity,
sleep, and, if appropriate, weight management. C
14.74 In addition to lifestyle modification, ACE inhibitors or angiotensin receptor blockers should
be started for treatment of confirmed hypertension (defined as blood pressure consistently
≥95th percentile for age, sex, and height or, in adolescents aged ≥13 years, ≥130/80 mmHg).
Due to the potential teratogenic effects, individuals of childbearing age should receive
reproductive counseling, and ACE inhibitors and angiotensin receptor blockers should be
avoided in individuals of childbearing age who are not using reliable contraception. B
14.75 The goal of treatment is blood pressure <90th percentile for age, sex, and height or, in
adolescents aged ≥13 years, <130/80 mmHg. C 307

Complications – Nephropathy (Type 2)
14.76 Urine albumin-to-creatinine ratio should be obtained at the time of diagnosis and annually
thereafter. An elevated urine albumin-to-creatinine ratio (>30 mg/g creatinine) should be confirmed on
two of three samples. B
14.77 Estimated glomerular filtration rate (GFR) should be determined at the time of diagnosis and
annually thereafter. E
14.78 In youth with diabetes and hypertension, either an ACE inhibitor or an angiotensin receptor
blocker is recommended for those with modestly elevated urinary albumin-to-creatinine ratio (30–299
mg/g creatinine) and should be considered for those with urinary albumin-to-creatinine ratio >300
mg/g creatinine and/or estimated GFR <60 mL/min/1.73 m2
. E Due to the potential teratogenic effects,
individuals of childbearing age should receive reproductive counseling, and ACE inhibitors and
angiotensin receptor blockers should be avoided in individuals of childbearing age who are not using
reliable contraception. B
14.79 For youth with nephropathy, continue monitoring (yearly and/or as indicated by urinary albumin-
to-creatinine ratio and estimated GFR) to detect disease progression. E
14.80 Referral to nephrology is recommended in case of uncertainty of etiology, worsening urinary
albumin-to-creatinine ratio, or decrease in estimated GFR. E 308

Complications – Neuropathy (Type 2)
14.81 Youth with type 2 diabetes should be screened for the presence of neuropathy by foot
examination at diagnosis and annually. The examination should include inspection,
assessment of foot pulses, pinprick and 10-g monofilament sensation tests, testing of
vibration sensation using a 128-Hz tuning fork, and ankle reflex tests. C
14.82 Prevention of neuropathy should focus on achieving glycemic goals. C
309

Complications – Retinopathy (Type 2)
14.83 Screening for retinopathy should be performed by dilated fundoscopy at or soon after
diagnosis and annually thereafter. C
14.84 Optimizing glycemia is recommended to decrease the risk or slow the progression of
retinopathy. B
14.85 Less frequent examination (every 2 years) may be considered if achieving glycemic
goals and a normal eye exam. C
14.86 Programs that use retinal photography (with remote reading or use of a validated
assessment tool) to improve access to diabetic retinopathy screening can be appropriate
screening strategies for diabetic retinopathy. Such programs need to provide pathways for
timely referral for a comprehensive eye examination when indicated. E
310

Prevention and Management of Diabetes Complications
– Metabolic-Associated Steatotic Liver Disease (Type 2)
14.87 Evaluation of youth with type 2 diabetes for metabolic dysfunction–associated
steatotic liver disease (by measuring AST and ALT) should be done at diagnosis and
annually thereafter. B
14.88 Referral to gastroenterology should be considered for persistently elevated or
worsening transaminases. B
311

Complications – Obstructive Sleep Apnea (Type 2)
14.89 Screening for symptoms of sleep apnea should be done at each visit, and referral to
a pediatric sleep specialist for evaluation and a polysomnogram, if indicated, is
recommended. Obstructive sleep apnea should be treated when documented. B
312

Complications – Polycystic Ovary Syndrome (Type 2)
14.90 Evaluate for polycystic ovary syndrome in female adolescents with type 2 diabetes,
including laboratory studies, when indicated. B
14.91 Metformin, in addition to lifestyle modification, is likely to improve the menstrual
cyclicity and hyperandrogenism in female individuals with type 2 diabetes. E
313

Complications – Cardiovascular Disease (Type 2)
14.92 Intensive lifestyle interventions focusing on weight loss, dyslipidemia, hypertension,
and dysglycemia are important to prevent overt macrovascular disease in early adulthood.
E
314

Complications – Dyslipidemia (Type 2)
14.93 Lipid screening should be performed initially after optimizing glycemia and annually
thereafter. B
14.94 Optimal goals are LDL cholesterol <100 mg/dL (<2.6 mmol/L), HDL cholesterol >35
mg/dL (>0.91 mmol/L), and triglycerides <150 mg/dL (<1.7mmol/L). E
14.95 If lipids are abnormal, initial therapy should consist of optimizing glycemia and
medical nutritional therapy to limit the amount of calories from fat to 25–30% and saturated
fat to <7%, limit cholesterol to<200mg/day, avoid trans fats, and aim for ~10% calories from
monounsaturated fats for elevated LDL. For elevated triglycerides, MNT should also focus
on decreasing carbohydrate intake and increasing dietary n-3 fatty acids in addition to the
above changes. A
315

Complications – Dyslipidemia (Type 2) continued
14.96 If LDL cholesterol remains >130 mg/dL (>3.4 mmol/L) after 6 months of dietary
intervention, initiate therapy with statin, with a goal of LDL <100 mg/dL (<2.6 mmol/L). Due
to the potential teratogenic effects, individuals of childbearing age should receive
reproductive counseling, and statins should be avoided in individuals of childbearing age
who are not using reliable contraception. B
14.97 If triglycerides are >400 mg/dL (>4.7 mmol/L) fasting or >1,000 mg/dL (>11.6 mmol/L)
nonfasting, optimize glycemia and begin fibrate, with a goal of <400 mg/dL (<4.7 mmol/L)
fasting to reduce risk for pancreatitis. C
316

Complications – Cardiac Function Testing (Type 2)
14.98 Routine screening for heart disease with electrocardiogram, echocardiogram, or
stress testing is not recommended in asymptomatic youth with type 2 diabetes. B
317

Complications – Psychosocial Factors (Type 2)
14.99 Health care professionals should screen for food insecurity, housing stability, health
literacy, financial barriers, and social or community support and apply that information to
treatment decisions. E
14.100 Use age-appropriate standardized and validated tools to screen for diabetes
distress, depressive symptoms, and behavioral health concerns in youth with type 2
diabetes, with attention to symptoms of depression and disordered eating, and refer to a
qualified behavioral health professional when indicated. B
14.101 Starting at puberty, preconception counseling should be incorporated into routine
diabetes clinic visits for all individuals of childbearing potential because of the adverse
pregnancy outcomes in this population. A
318

Substance Use in Pediatric Diabetes – Tobacco,
Electronic Cigarettes, Alcohol, and Cannabis
14.102 Adolescents and young adults should be screened for tobacco or nicotine,
electronic cigarettes, substance use, and alcohol use at diagnosis and regularly thereafter.
C
14.103 Elicit a smoking history at initial and follow-up diabetes visits; discourage smoking in
youth who do not smoke and encourage smoking cessation in those who do smoke. A
14.104 Electronic cigarette use or vaping should be discouraged. A
14.105 Advise all youth with diabetes not to use cannabis recreationally in any form. E
319

Transition from Pediatric to Adult Care
14.106 Diabetes care teams should implement transition preparation programs for youth
beginning in early adolescence and, at the latest, at least 1 year before the anticipated
transfer from pediatric to adult health care. E
14.107 Interprofessional adult and pediatric health care teams should provide support and
resources for adolescents, young adults, and their families prior to and during the transfer
process from pediatric to adult health care. C
14.108 Pediatric diabetes specialists should partner with youth with diabetes and their
caregivers to engage in shared decision-making for the timing of transfer to an adult
diabetes specialist. There is no age-specific cutoff for youth with diabetes to transfer to an
adult diabetes specialist. E
320

Section 15
Management of Diabetes in Pregnancy

Preconception Counseling
15.1 Starting at puberty and continuing in all people with diabetes and childbearing
potential, preconception counseling should be incorporated into routine diabetes care. A
15.2 Family planning should be discussed, and effective contraception (with consideration
of long-acting, reversible contraception) should be prescribed and used until an individual’s
treatment plan and A1C are optimized for pregnancy. A
15.3 Preconception counseling should address the importance of achieving glucose levels
as close to normal as is safely possible, ideally A1C <6.5% (<48 mmol/mol), to reduce the
risk of congenital anomalies, preeclampsia, macrosomia, preterm birth, and other
complications. A
15.4 Individuals with a history of gestational diabetes mellitus (GDM) should seek
preconception screening for diabetes and preconception care to identify and treat
hyperglycemia and prevent congenital malformations. E
322

Preconception Care
15.5 Individuals with preexisting diabetes who are planning a pregnancy should ideally
begin receiving interprofessional care for preconception, which includes an endocrinology
health care professional, maternal-fetal medicine specialist, registered dietitian nutritionist,
and diabetes care and education specialist, when available. B
15.6 In addition to focused attention on achieving glycemic goals, A standard preconception
care should be augmented with extra focus on nutrition, physical activity, diabetes self-care
education, and screening for diabetes comorbidities and complications. B
15.7 Individuals with preexisting diabetes who are planning a pregnancy or who have
become pregnant should be counseled on the risk of development and/or progression of
diabetic retinopathy. Dilated eye examinations should occur ideally before pregnancy as
well as in the first trimester, and then pregnant individuals should be monitored every
trimester and for 1 year postpartum as indicated by the degree of retinopathy and as
recommended by the eye care health care professional. B
323

324
Management of Diabetes in Pregnancy:

Glycemic Goals in Pregnancy
15.8 Fasting, preprandial, and postprandial blood glucose monitoring are recommended in
individuals with diabetes in pregnancy to achieve optimal glucose levels. Glucose goals are
fasting plasma glucose <95 mg/dL (<5.3 mmol/L) and either 1-h postprandial glucose <140
mg/dL (<7.8 mmol/L) or 2-h postprandial glucose <120 mg/dL (<6.7 mmol/L). B
15.9 Due to increased red blood cell turnover, A1C is slightly lower during pregnancy in
people with and without diabetes. Ideally, the A1C goal in pregnancy is <6% (<42
mmol/mol) if this can be achieved without significant hypoglycemia, but the goal may be
relaxed to <7% (<53 mmol/mol) if necessary to prevent hypoglycemia. B
15.10 Continuous glucose monitoring (CGM) can help to achieve glycemic goals (e.g., time
in range, time above range) A and A1C goal B in type 1 diabetes and pregnancy, and may
be beneficial for other types of diabetes in pregnancy. E
325

Glycemic Goals in Pregnancy
15.11 Recommend CGM to pregnant individuals with type 1 diabetes. A In conjunction with
aims to achieve traditional pre- and postprandial glycemic goals, real-time CGM can reduce
the risk for large-for-gestational-age infants and neonatal hypoglycemia in pregnancy
complicated by type 1 diabetes. A
15.12 CGM metrics may be used in combination with blood glucose monitoring to achieve
optimal pre- and postprandial glycemic goals. E
15.13 Commonly used estimated A1C and glucose management indicator calculations
should not be used in pregnancy as estimates of A1C. C
326

327
Management of Diabetes in Pregnancy:

15.14 Nutrition counseling before and during pregnancy should promote an eating pattern
including fruits, vegetables, legumes, whole grains, nuts, seeds, fish, and other lean
protein, which will provide a balance of macronutrients and healthy n-3 fatty acids. C
15.15 Lifestyle behavior change is an essential component of management of GDM and
may suffice as treatment for many individuals. Insulin should be added if needed to achieve
glycemic goals. A
15.16 Telehealth visits used in combination with in-person visits for pregnant people with
GDM can improve outcomes compared with standard in-person care alone. A
15.17 Insulin should be used to manage type 1 diabetes in pregnancy A and is the
preferred agent for the management of GDM A and type 2 diabetes B in pregnancy.
15.18 Either multiple daily injections or insulin pump technology can be used in pregnancy
complicated by type 1 diabetes. C
328

(continued)
15.19 Automated insulin delivery (AID) systems with pregnancy-specific glucose targets are
recommended for pregnant individuals with type 1 diabetes. A
15.20 AID systems without pregnancy-specific glucose targets or a pregnancy-specific
algorithm may be considered for select pregnant individuals with type 1 diabetes when
used with assistive techniques and working with experienced health care teams. B
15.21 Metformin and glyburide, individually or in combination, should not be used as first-
line agents for management of diabetes in pregnancy, as both cross the placenta to the
fetus A and may not be sufficient to achieve glycemic goals. B Other oral and noninsulin
injectable glucose-lowering medications lack long-term safety data and are not
recommended. E
15.22 Metformin, when used to treat polycystic ovary syndrome and induce ovulation,
should be discontinued by the end of the first trimester. A
329

Preeclampsia and Aspirin
15.23 Pregnant individuals with type 1 or type 2 diabetes should be prescribed low-dose
aspirin 100–150 mg/day starting at 12–16 weeks of gestation to lower the risk of
preeclampsia. E A dosage of 162 mg/day may be acceptable; E currently, in the U.S., low-
dose aspirin is available in 81-mg tablets.
330

Pregnancy and Drug Considerations
15.24 In pregnant individuals with diabetes and chronic hypertension, a blood pressure
threshold of 140/90 mmHg for initiation or titration of therapy is associated with better
pregnancy outcomes than reserving treatment for severe hypertension, with no increase in
risk of small-for-gestational-age birth weight. A There are limited data on the optimal lower
limit, but therapy should be deintensified for blood pressure <90/60 mmHg. E A blood
pressure goal of 110–135/85 mmHg is suggested in the interest of reducing the risk for
accelerated maternal hypertension. A
15.25a Potentially harmful medications in pregnancy (e.g., ACE inhibitors, angiotensin
receptor blockers, mineralocorticoid receptor antagonists) should be stopped prior to
conception and avoided in sexually active individuals of childbearing potential who are not
using reliable contraception. B
15.25b In most circumstances, lipid-lowering medications should be stopped prior to
conception and avoided in sexually active individuals of childbearing potential with diabetes
who are not using reliable contraception. B In some circumstances (familial
hypercholesterolemia, prior atherosclerotic cardiovascular disease event), statin therapy
may be continued when the benefits outweigh risks. E 331

Postpartum Care
15.26 Insulin requirements need to be evaluated and adjusted for individuals requiring insulin
after delivery because insulin resistance decreases dramatically immediately postpartum. C
15.27 A contraceptive plan should be discussed and implemented with all people with
diabetes of childbearing potential. A
15.28 Breastfeeding efforts are recommended for all individuals with diabetes. A
Breastfeeding is recommended for individuals with a history of GDM for multiple benefits, A
including a reduced risk for type 2 diabetes later in life. B
15.29 Postpartum care should include psychosocial assessment and support for self-care. E
15.30 Screen individuals with a recent history of GDM at 4–12 weeks postpartum, using the
75-g oral glucose tolerance test and clinically appropriate nonpregnancy diagnostic criteria. B
15.31 Individuals with a history of GDM should have lifelong screening for the development of
type 2 diabetes or prediabetes every 1–3 years. B
15.32 Individuals with overweight or obesity and a history of GDM found to have prediabetes
should receive intensive lifestyle interventions and/or metformin to prevent diabetes. A 332

Section 16.
Diabetes Care in the Hospital

Hospital Care Delivery Standards
16.1 Perform an A1C test on all people with diabetes or hyperglycemia (random blood
glucose >140 mg/dL [>7.8 mmol/L]) admitted to the hospital if no A1C test result is available
from the prior 3 months. B
16.2 Institutions should implement protocols using validated written or computerized
provider order entry sets for management of dysglycemia in the hospital that allow for a
personalized approach. B
334

Diabetes Care Specialists in the Hospital
16.3 When caring for hospitalized people with diabetes (with an existing or new diagnosis)
or stress hyperglycemia, consult with a specialized diabetes or glucose management team
when available. B
335

Glycemic Goals in Hospitalized Adults
16.4a Insulin should be initiated or intensified for treatment of persistent hyperglycemia
starting at a threshold of ≥180 mg/dL (≥10.0 mmol/L) (confirmed on two occasions within 24
h) for the majority of critically individuals (those in the intensive care unit [ICU]). A
16.4b Insulin and/or other glucose-lowering therapies should be initiated or intensified for
treatment of persistent hyperglycemia starting at a threshold of ≥180 mg/dL (≥10.0 mmol/L)
(confirmed on two occasions within 24 h) for the majority of noncritically ill individuals (those
not in the ICU). B
16.5a Once therapy is initiated, a glycemic goal of 140–180 mg/dL (7.8–10.0 mmol/L) is
recommended for most critically ill individuals (those in the ICU) with hyperglycemia. A
More stringent individualized glycemic goals may be appropriate for selected critically ill
individuals if they can be achieved without significant hypoglycemia. B
16.5b For noncritically ill individuals (those not in the ICU), a glycemic goal of 100–180
mg/dL (5.6–10.0 mmol/L) is recommended if it can be achieved without significant
hypoglycemia. B
336

Continuous Glucose Monitoring
16.6 In people with diabetes using a personal continuous glucose monitoring (CGM)
device, the use of CGM should be continued during hospitalization if clinically appropriate,
with confirmatory point-of-care (POC) blood glucose measurements for insulin dosing
decisions and hypoglycemia assessment, if resources and training are available, and
according to an institutional protocol. B
16.7 Continue use of insulin pump or automated insulin delivery in people with diabetes
who are hospitalized when clinically appropriate, with confirmatory POC blood glucose
measurements for insulin dosing decisions and hypoglycemia assessment and treatment.
This is contingent upon availability of necessary supplies, resources, and training, ongoing
competency assessments, and implementation of institutional diabetes technology
protocols. C
337

Insulin Therapy
16.8a Continuous intravenous insulin infusion is recommended for achieving glycemic
goals and avoiding hypoglycemia in critically ill individuals. A
16.8b Basal insulin or a basal plus bolus correction insulin plan is the preferred treatment
for noncritically ill hospitalized individuals with poor or no oral intake. A
16.9 An insulin plan with basal, prandial, and correction components is the preferred
treatment for most noncritically ill hospitalized individuals with adequate nutritional intake. A
16.10 For most individuals, sole use of a correction or supplemental insulin without basal
insulin (formerly referred to as a sliding scale) in the inpatient setting is discouraged. A
338

Noninsulin Therapies
16.11 For people with type 2 diabetes hospitalized with heart failure, it is recommended that
use of a sodium-glucose cotransporter 2 inhibitor be initiated or continued during
hospitalization and upon discharge, if there are no contraindications and after recovery from
the acute illness. A
339

Hypoglycemia
16.12 A hypoglycemia management surveillance protocol should be adopted by all health
systems. A plan for identifying, treating, and preventing hypoglycemia should be
established for each individual. Episodes of hypoglycemia in the hospital should be
documented in the health record and tracked to inform quality improvements. C
16.13 Treatment plans should be reviewed and changed as necessary to prevent
hypoglycemia and recurrent hypoglycemia when a blood glucose value of <70 mg/dL (<3.9
mmol/L) is documented. C
340

To reduce surgical risk in these individuals, some institutions (126,128,129) have A1C cutoffs for
elective surgeries, and some have developed optimization programs to lower A1C prior to surgery
(126,128–130). The following approaches (126,128,130) may be considered:
 1. A preoperative risk assessment should be performed for people with diabetes who are at high risk
for ischemic heart disease and those with autonomic neuropathy or renal failure.
 2. The A1C goal for elective surgeries should be <8% (<64.0 mmol/L) whenever possible.
 3. The blood glucose goal in the perioperative period should be 100–180 mg/dL (5.6–10.0 mmol/L)
(126) within 4 h of the surgery. CGM should not be used alone for glucose monitoring during surgery
(129).
 4. Metformin should be held on the day of surgery.
 5. SGLT2 inhibitors should be discontinued 3–4 days before surgery.
 6. Other oral glucose-lowering agents should be held the morning of surgery or procedure.
 7. Insulin dose reductions include NPH insulin to one-half of the dose or long-acting basal insulin
analogs to 75–80% of the dose or adjustment of insulin pump (if not in automated mode) basal rates
based on the type of diabetes and clinical judgment (see Section 7, “Diabetes Technology”).
 8. Monitor blood glucose at least every 2–4 h while the individual takes nothing by mouth and
administer short or rapid-acting insulin as needed.
341

 9. Stricter perioperative glycemic goals are not advised, as perioperative glycemic goals stricter
than 80–180 mg/dL (4.4–10.0 mmol/L) may not improve outcomes and are associated with
increased hypoglycemia (128).
 10. Compared with usual dosing, a reduction of 25% of basal insulin dose given the evening before
surgery is more likely to achieve perioperative blood glucose goals with a lower risk for
hypoglycemia (131).
 11. In individuals undergoing noncardiac general surgery, basal insulin plus premeal short- or rapid-
acting insulin (basal-bolus) coverage has been associated with improved glycemic outcomes and
lower rates of perioperative complications compared with the reactive, correction-only short- or
rapid-acting insulin coverage alone with no basal insulin dosing (60,126).
 12. There is little data on the safe use and/or influence of GLP-1 RAs on glycemia and delayed
gastric emptying in the perioperative period. With increasing use of GLP-1 RA and dual glucose-
dependent insulinotropic polypeptide (GIP) and GLP-1 RA medications for diabetes and/or weight
loss, there are concerns about the safety of these drugs in the perioperative period. These drugs
may be associated with nausea, vomiting, and delayed gastric emptying and have the potential to
increase the risk of pulmonary aspiration during general anesthesia and deep sedation. The
American Society of Anesthesiologists recommends holding GLP-1 RAs on the day of the
procedure or surgery for daily dose agents and for at least 7 days prior to the procedures or surgery
for once-weekly dose agents (132).
342

Diabetic Ketoacidosis and Hyperglycemic
Hyperosmolar State
16.14 Manage diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS)
by administering intravenous fluids, insulin, and electrolytes (Fig. 16.1) and by closely
monitoring during treatment, ensuring timely and bridged transition to maintenance
subcutaneous insulin administration, and identifying and treating the precipitating cause. A
16.15 The discharge planning process should include education on the recognition,
prevention, and management of DKA and/or HHS for all individuals affected by or at high
risk for these events to prevent recurrence and readmission. B
343

344
Diabetes Care in the Hospital:

345
Diabetes Care in the Hospital:

Transition from the Hospital to the
Ambulatory Setting
16.16 A structured discharge plan should be tailored to the individual with diabetes. B
346

Section 17.
Diabetes Advocacy

Select Diabetes Advocacy Statements
 Diabetes Care in the School Setting
 Diabetes and Driving
 Diabetes Management in Detention Facilities
 Care of Young Children with Diabetes in the Childcare and Community Setting
 Insulin Access and Affordability
 Diabetes and Employment
348
17. Diabetes Advocacy

2025-ADA-SOC-Slide-Deck-all-recommendations-FINAL-12-9-24.pptx

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2025-ADA-SOC-Slide-Deck-all-recommendations-FINAL-12-9-24.pptx

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