Diabetes Care 2025 Standards of Care PDF

S6 Diabetes Care Volume 48, Supplement 1, January 2025 Summary of Revisions: Standards American Diabetes Associ...

S6 Diabetes Care Volume 48, Supplement 1, January 2025 Summary of Revisions: Standards American Diabetes Association Professional Practice Committee* of Care in Diabetes—2025 Diabetes Care 2025;48(Suppl. 1):S6–S13 | https://doi.org/10.2337/dc25-SREV Downloaded from http://diabetesjournals.org/care/article-pdf/48/Supplement_1/S6/791587/dc25srev.pdf by guest on 23 December 2024 GENERAL CHANGES for Bone and Mineral Research and how to implement and sustain interven- The field of diabetes care is rapidly chang- Section 8, “Obesity and Weight Manage- tions that improve care delivery and pop- ing as new research, technology, and treat- ment for the Prevention of Type 2 Dia- ulation health. ments that can improve the health and betes,” received endorsement from The Recommendation 1.6 was added to SUMMARY OF REVISIONS well-being of people with diabetes con- Obesity Society. For the seventh consec- emphasize the importance of assessing tinue to emerge. With annual updates utive year, Section 10, “Cardiovascular Dis- and addressing disparities in diabetes care since 1989, the American Diabetes Associ- ease and Risk Management,” received and health outcomes. The text includes ac- ation has long been a leader in producing endorsement from the American College of tionable guidance on measuring health guidelines that capture the most current Cardiology. For the first time, Section 13, disparities and engaging interprofessional state of the field. “Older Adults,” received endorsement teams and community partners to address The 2025 “Standards of Care in Dia- from the American Geriatrics Society. them. betes” has continued to incorporate Recommendation 1.7 was revised to person-first and inclusive language. Efforts Section 1. Improving Care and emphasize the importance of screening were made to consistently apply terminol- Promoting Health in Populations for and addressing multiple social deter- ogy that empowers people with diabetes (https://doi.org/10.2337/dc25-S001) minants of health that impact diabetes and recognizes the individual at the center Recommendation 1.1 was expanded to management, health outcomes, and qual- of diabetes care. include people at risk for diabetes in ad- ity of life. Although levels of evidence for several dition to those with diabetes. The narrative text now includes an ex- recommendations have been updated, Recommendation 1.2 was revised to in- panded discussion of cost and affordability these changes are not outlined below clude, in addition to the Chronic Care considerations as well as health disparities where the clinical recommendation has Model, other evidence-based care delivery and social determinants of health. remained the same. That is, changes in ev- models and frameworks that have been Table 1.1 was added to highlight the idence level from, for example, E to C, are demonstrated to improve diabetes care importance of engaging an interprofes- not noted below. The 2025 Standards of delivery and health outcomes. These in- sional team approach to person-centered Care contains, in addition to many minor clude the Patient-Centered Medical Home care for people with diabetes across the changes that clarify recommendations or model, Accountable Care Organizations, life span. reflect new evidence, more substantive re- and value-based payment models and are visions detailed below. discussed in the text. Section 2. Diagnosis and Recommendation 1.5 was added to em- Classification of Diabetes SECTION CHANGES phasize the importance of quality improve- (https://doi.org/10.2337/dc25-S002) Endorsements ment initiatives and interprofessional teams Table 2.3 was added to provide consid- For the second consecutive year, the for supporting sustainable and scalable erations related to the use and inter- “Bone Heath” subsection in Section 4, process changes that improve quality of pretation of laboratory measurement of “Comprehensive Medical Evaluation and care and health outcomes. Implementa- glucose and A1C. Assessment of Comorbidities,” received tion concepts were added throughout the The “Classification” subsection has been endorsement from the American Society section to provide actionable guidance on updated to provide a pragmatic approach *A complete list of members of the American Diabetes Association Professional Practice Committee can be found at https://doi.org/10.2337/dc25-SINT. Duality of interest information for each author is available at 10.2337/dc25-SDIS. Suggested citation: American Diabetes Association Professional Practice Committee. Summary of revisions: Standards of Care in Diabetes—2025. Diabetes Care 2025;48(Suppl. 1):S6–S13 © 2024 by the American Diabetes Association. Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. More information is available at https://www.diabetesjournals.org/journals/pages/license. diabetesjournals.org/care Summary of Revisions S7 to management of individuals who have previous treatment at the initial visit and urinary tract infections. Recommendation features of both type 1 and type 2 diabetes. follow-up visits as appropriate. 4.21 was added to state that health care In the “Type 1 Diabetes” subsection, Table 4.2 was amended to include es- professionals should screen for symptoms Recommendation 2.7 was added to em- sential components for assessment, plan- and/or signs of genitourinary syndrome of phasize the importance of antibody-based ning, and referral as appropriate. menopause. screening for presymptomatic type 1 dia- Changes were made in the “Immu- The terminology for nonalcoholic fatty betes in individuals with a family history nizations” subsection to reflect updates liver disease (NAFLD) and nonalcoholic stea- of type 1 diabetes or otherwise known el- for COVID-19, pneumococcal pneumonia, tohepatitis (NASH) was updated to meta- evated genetic risk. The associated text influenza, and respiratory syncytial virus. bolic dysfunction–associated steatotic liver was also updated and expanded to reflect Table 4.3 was revised to include impor- disease (MASLD) and metabolic dysfunction– these changes. tant vaccination updates. associated steatohepatitis (MASH), respec- The “Gestational Diabetes Mellitus” Recommendation 4.6 was modified to tively. This updated nomenclature was incor- subsection was completely updated to fa- specify initial and repeat screening for porated throughout the section. Downloaded from http://diabetesjournals.org/care/article-pdf/48/Supplement_1/S6/791587/dc25srev.pdf by guest on 23 December 2024 cilitate understanding and implementa- autoimmune thyroid disease. Recommendation 4.22a was revised tion of the current various approaches to Recommendation 4.10 was updated to to specify when to screen for the risk of screening for and diagnosis of gestational specify avoiding medications with known having or developing cirrhosis related to diabetes mellitus (GDM). association with higher fracture risk. MASH using the calculated fibrosis-4 in- The text in various other subsections, Recommendation 4.12 was revised to dex (FIB-4). including those that discuss diabetes and include the recommended intake of cal- Recommendation 4.23 was amended immune checkpoint inhibitors, the role of cium for people with diabetes. to state that adults with type 2 diabetes or the gut microbiome in diabetes risk, and Recommendation 4.13 was updated to prediabetes and a FIB-4 >1.3 should have monogenic diabetes, was updated. specify when antiresorptive medications and additional risk stratification performed. osteoanabolic agents should be considered. Recommendation 4.24 was revised to Section 3. Prevention or Delay of Table 4.4 was updated to specify when state that individuals with a higher risk for Diabetes and Associated bone mineral density testing should be significant liver fibrosis should be referred Comorbidities performed. to a gastroenterologist or hepatologist. (https://doi.org/10.2337/dc25-S003) A new subsection, “Dental Care,” was Recommendation 4.25 was revised to in- In the “Lifestyle Behavior Change for added and includes two new recommen- clude an interprofessional team approach Type 2 Diabetes Prevention” subsection, dations. Recommendation 4.15 was added when promoting weight loss, particularly text pertaining to sleep health in relation to state people with diabetes should be re- with a structured nutrition plan and physi- to risk of type 2 diabetes was added. This ferred for a dental exam at least once per cal activity program for cardiometabolic addition highlights sleep as a central year. Recommendation 4.16 was added to benefits and histological improvement. component in the management of predi- state that efforts between medical and Recommendation 4.26 was revised to abetes and type 2 diabetes, placing it on dental teams should be coordinated so include a dual glucose-dependent insuli- a level playing field with other lifestyle that glucose-lowering medications can be notropic polypeptide (GIP) and glucagon behaviors (e.g., physical activity and eat- appropriately adjusted prior to and in the like peptide 1 (GLP-1) receptor agonist (RA) ing patterns). post–dental procedure period as needed. with potential benefits in MASH as an ad- In the “Pharmacologic Interventions to Recommendation 4.17 was updated junctive therapy to lifestyle interventions Delay Type 2 Diabetes” subsection, the to reflect that an assessment for disabil- for weight loss in adults with type 2 diabe- text on the proposed use of vitamin D ity should be performed at the initial tes, MASLD, and overweight or obesity. therapy to prevent type 2 diabetes was ex- visit and an assessment for decline in Recommendation 4.27a was revised tensively updated. The text related to long- function should be performed at each to state that in adults with type 2 diabe- term metformin therapy and associated subsequent visit. tes and biopsy-proven MASH or those vitamin B12 deficiency was also updated. Recommendation 4.18 was modified to at high risk for liver fibrosis, use of pio- The language in Recommendation 3.15 include inquiring about sexual health in glitazone or a GLP-1 RA or a dual GIP was strengthened to facilitate discussion men and to screen with a morning serum and GLP-1 RA is preferred for glycemic with selected individuals aged $8 years with total testosterone if symptoms and/or management due to potential beneficial stage 2 type 1 diabetes about the role of te- signs of hypogonadism are present. effects on MASH. plizumab-mzwv infusion to delay the onset Recommendation 4.19 was added to Recommendation 4.27b was added to of symptomatic type 1 diabetes (stage 3). specifically state that men with diabetes state that combination therapy with pio- or prediabetes should be screened for glitazone and a GLP-1 RA can be consid- Section 4. Comprehensive Medical erectile dysfunction, and new text was ered for treatment of hyperglycemia in Evaluation and Assessment of added on erectile dysfunction. adults with type 2 diabetes with biopsy- Comorbidities A new subsection, “Female Sexual Dys- proven MASH or those at high risk of (https://doi.org/10.2337/dc25-S004) function,” was added and includes two liver fibrosis because of potential benefi- Language in Fig. 4.1 was updated, and new recommendations. Recommendation cial effects of such a combination on Table 4.1 was modified to include changes 4.20 states that health care professionals MASH. made throughout Section 4. should inquire about sexual health, particu- Recommendation 4.28 was added to Recommendation 4.3 was changed to larly in women who experience depression state that treatment with a thyroid hor- include assessment for glycemic status and and/or anxiety and those with recurrent mone receptor-b agonist in adults with S8 Summary of Revisions Diabetes Care Volume 48, Supplement 1, January 2025 type 2 diabetes or prediabetes with MASLD with overweight or obesity, aiming for at Additionally, newly added Fig. 5.1 il- with moderate (F2) or advanced (F3) liver least 3–7% weight loss. lustrates differences and similarities be- fibrosis may be considered and that the in- Recommendation 5.14 on eating pat- tween religious and intermittent fasting dividual should be referred to a gastroen- terns now has revised verbiage to include for people with diabetes. Table 5.4 in- terologist or hepatologist with expertise in processed foods, lean proteins, and non- cludes a risk calculation and suggested MASLD management for the initiation and dairy alternatives. risk score for people with diabetes who monitoring of this therapy. Recommendation 5.16 was updated seek to fast during Ramadan, and Table 5.5 Recommendation 4.29 was added to to include actionable language and clar- includes information about medication emphasize that treatment initiation and ity regarding the use of dietary supple- changes during fasting. monitoring should be individualized and ments for glycemic benefits. In the “Physical Activity” subsection, within the context of an interprofessional Recommendations 5.17 and 5.18 were Recommendation 5.34 was updated to team for MASLD and MASH management. updated to have revised and actionable include a statement about limiting the Figure 4.2 was revised to reflect impor- language, respectively. amount of time spent sedentary, which Downloaded from http://diabetesjournals.org/care/article-pdf/48/Supplement_1/S6/791587/dc25srev.pdf by guest on 23 December 2024 tant updates to the diagnostic algorithm Recommendation 5.19 was updated includes recreational screen time. for risk stratification and the prevention to use actionable language. Recommendation 5.38 was modified of cirrhosis in individuals MASLD, and new Recommendation 5.20 was revised to to state that prolonged sitting should Fig. 4.3 includes the MASLD treatment recommend limiting sodium as clinically be interrupted at least every 30 min for algorithm. appropriate, which can be done, in part, glycemic benefits. by limiting consumption of processed Recommendation 5.39 was added to Section 5. Facilitating Positive Health foods. counsel adults and youth receiving weight Behaviors and Well-being to Improve Recommendation 5.21 was modified to management pharmacotherapy or meta- Health Outcomes recommend water over nutritive and non- bolic surgery to meet physical activity rec- (https://doi.org/10.2337/dc25-S005) nutritive sweetened beverages, and Rec- ommendations. The accompanying text In the “Diabetes Self-Management Educa- ommendation 5.22 was added to state addresses the concern of sarcopenic obe- tion and Support” subsection, Recom- that nonnutritive sweeteners can be used sity with use of incretin therapies and mendation 5.1 was updated to emphasize instead of sugar-sweetened products in metabolic surgery. that all people with diabetes should be moderation and for short term to reduce In the “Smoking Cessation: Tobacco, advised to participate in diabetes self- overall calorie and carbohydrate intake. E-cigarettes, and Cannabis” subsection, management education and support Recommendation 5.23 was added to Recommendation 5.42 was added to advise (DSMES) rather than being just encour- emphasize the screening for malnutrition, people with type 1 diabetes and those with aged to participate. especially for those who have undergone other forms of diabetes at risk for diabetic Recommendation 5.2 was updated to metabolic surgery and for those being ketoacidosis (DKA) to not use recreational clarify when to provide DSMES. treated with weight management phar- cannabis in any form due to the risk of can- Recommendation 5.3 was revised to macological therapies. nabis hyperemesis syndrome. The accompa- be more succinct and action-oriented, Recommendation 5.25 was revised to nying text describes cannabis hyperemesis placing emphasis on routine assessment use actionable language. syndrome and its diagnostic criteria. of key goals of DSMES. Recommendation 5.26 was added to Recommendation 5.43 in “Supporting Recommendation 5.4 was added to address the issue of sodium–glucose co- Positive Health Behaviors” was updated to emphasize the importance of screening transporter (SGLT) inhibition being asso- include health-related quality of life as an for behavioral health concerns at the ciated with ketoacidosis under certain outcome when using behavioral health same time points as evaluating the need conditions. It provides guidance on aware- strategies to support self-management and for DSMES. ness, prevention, risk mitigation, and die- healthy behaviors. Language in Recommendation 5.5 was tary adjustments. Recommendation 5.45 in “Psychosocial updated to state that DSMES should be Recommendation 5.29 was added to Care” was revised to state the specific psy- culturally appropriate and responsive to encourage intake of plant-based proteins chosocial concerns health care professio- individual preferences, needs, and values. and fiber, and Recommendation 5.31 was nals should screen for including diabetes Recommendation 5.6 was updated to added to encourage limiting foods high in distress, depression, anxiety, fear of hypo- reflect the now-common practice of re- saturated fats to reduce cardiovascular glycemia, and disordered eating behaviors. mote-delivery of DSMES and reimburse- disease risk. Recommendation 5.48 in “Diabetes ment for remotely delivered modalities. Two new recommendations were added Distress” was updated to recommend the Recommendation 5.9 was updated to for religious fasting. Recommendation 5.32 frequency of at least annual screening for reinforce the importance of screening states to use the Diabetes and Ramadan diabetes distress in people with diabetes, for and including social determinants of International Alliance comprehensive pre- caregivers, and family members. health in guiding the design and deliv- fasting risk assessment for risk stratifica- Recommendation 5.49 in “Anxiety” was ery of DSMES. tion of people with diabetes prior to updated to recommend screening for anxi- In the “Medical Nutrition Therapy” sub- engaging in religious fasting. Recommen- ety, which is in accordance with the U.S. section, Recommendation 5.12 was updated dation 5.33 was created to provide guid- Preventive Services Task Force recommen- to emphasize the importance of providing ance to health care professionals caring dation for screening for anxiety. treatment based on nutrition, physical activ- for people with diabetes who participate Recommendation 5.50 in “Anxiety” was ity, and behavioral therapy for individuals in religious fasting. added to include a recommendation for diabetesjournals.org/care Summary of Revisions S9 screening for fear of hypoglycemia in peo- subcutaneous insulin infusion and auto- Recommendation 7.29 was modified ple with diabetes at risk for hypoglycemia mated insulin delivery (AID) systems to include provision of support and dia- or fear of hypoglycemia. should be standardized with at a minimum betes management advice in people with Recommendation 5.51 in “Depression” the ambulatory glucose profile and weekly diabetes using open-source closed-loop was modified to have more actionable summary. In addition, there should be systems. language for the importance of depres- options for raw data or daily and weekly The text for open-source closed-loop sion rescreening. reports available to the health care systems was also expanded to include Recommendation 5.54 in “Disordered professionals. the most recent published evidence on Eating Behavior” was updated to recom- Recommendation 7.14 was modified to the safety and effectiveness of these mend screening for disordered or disrupted make the clinician aware of potential in- systems in people with type 1 diabetes. eating using validated screening measures. terference of medications and other sub- Recommendation 7.30 was expanded The accompanying text describes the disor- stances on glucose levels measured by to include the benefits of combining dered or disrupted eating behaviors com- blood glucose meters. technology with online or virtual coach- Downloaded from http://diabetesjournals.org/care/article-pdf/48/Supplement_1/S6/791587/dc25srev.pdf by guest on 23 December 2024 monly reported in people with diabetes. Table 7.2 was modified to include the ing to improve glycemic outcomes in in- Tables 5.7 and 5.8 were added to il- various potential substances or medical dividuals with diabetes and prediabetes. lustrate psychosocial concerns and their conditions that may affect glucose levels Recommendation 7.32 was refined to association with diabetes-related out- when measured by blood glucose meters. emphasize the importance of continuing comes in adults with type 1 and type 2 Table 7.3 was modified to include the the use of insulin pumps or AID in people diabetes, respectively. description of over-the-counter CGM with diabetes while hospitalized when devices. clinically appropriate and with confirma- Section 6. Glycemic Goals and Recommendation 7.15 was modified to tory point-of-care blood glucose meas- Hypoglycemia support the use of real-time CGM (rtCGM) urements for insulin dose adjustments (https://doi.org/10.2337/dc25-S006) and intermittently scanned CGM (isCGM) and hypoglycemia assessment and treat- Recommendation 6.12 was added to for youth and adults with diabetes (type 1 ment. The use of these devices in the in- promote routine screening for fear of or type 2) on any type of insulin therapy patient setting should be contingent on hypoglycemia in individuals at risk for based on the most recent literature. the availability of infrastructure sup- hypoglycemia. Recommendation 7.16 was added to port and institutional diabetes technol- A new subsection entitled “Hyperglycemic consider the use of rtCGM or isCGM in ogy protocols. Crises: Diagnosis, Management, and Pre- adults with type 2 diabetes on glucose- vention” was added to cover the epidemi- lowering agents other than insulin to Section 8. Obesity and Weight ology, diagnostic criteria, and outpatient achieve and maintain individualized gly- Management for the Prevention and prevention of DKA and the hyperglycemic cemic goals. Treatment of Type 2 Diabetes hyperosmolar state (HHS). Recommendation 7.18 was modified (https://doi.org/10.2337/dc25-S008) New recommendations on routine as- to align with Section 15, “Management Recommendation 8.2a was updated to sessment of history of DKA and HHS of Diabetes in Pregnancy,” and reflect clarify that additional measurements of (recommendation 6.20) and providing the update of CGM benefits in type 1 body fat distribution are warranted if structured prevention education (Rec- diabetes and pregnancy and other types BMI is indeterminant. ommendation 6.21) in the outpatient of diabetes in pregnancy. Recommendation 8.2b was revised to setting were added. The text on CGM was expanded to in- recommend monitoring of obesity-related Tables 6.9 and 6.10 were added and clude the updated sensors integrated with anthropometric measurements at least include risk factors for hyperglycemic AID systems and to update the most re- every 3 months during active weight man- crises as well as clinical presentation of cent literature evidence supporting the agement treatment. DKA and HHS in people with diabetes, benefits of CGM in individuals with type 2 Discussion of weight stigma and bias respectively. diabetes on glucose-lowering agents other toward people living in larger bodies was Figure 6.2 was revised to provide a spe- than insulin from clinical trials and real- added to the text. cific and actionable approach to selecting world studies. Furthermore, the CGM sec- Recommendation 8.11 was enhanced to individual glycemic goals, accounting for tion was expanded to include the need to reflect the importance of continued moni- health status and other person- and treat- standardize any diabetes technology de- toring, support, and interventions for indi- ment-specific factors favoring more or vice reports and to provide clinicians not viduals who have achieved weight loss less stringent goals. only with single page summaries but also goals to support the maintenance of these with access to detailed reports and even goals long term. Section 7. Diabetes Technology raw data from devices, especially those Recommendation 8.18 was added to (https://doi.org/10.2337/dc25-S007) reporting insulin dose modifications, such recommend screening for malnutrition for Recommendation 7.8 was modified to as AID systems. people with diabetes and obesity who emphasize consideration for starting dia- The text on insulin pumps and AID sys- have lost significant weight. betes technology early, even at diagnosis. tems was greatly expanded to discuss Recommendation 8.19 was added to Recommendation 7.9 was added to the features of the various AID systems recommend continuing weight manage- emphasize that reports for all continuous and their data from pivotal trials and ment pharmacotherapy, as indicated, be- glucose monitoring (CGM) devices, con- real-world studies in type 1 and type 2 yond reaching weight loss goals to maintain nected insulin devices, and continuous diabetes. health benefits and avoid weight regain S10 Summary of Revisions Diabetes Care Volume 48, Supplement 1, January 2025 and worsening of cardiometabolic abnor- health outcomes for individuals with these of overbasalization including significant malities that often result from sudden conditions irrespective of A1C. bedtime-to-morning or postprandial-to- discontinuation of weight management Recommendation 9.12 was added to preprandial glucose differential, occur- pharmacotherapy. recommend use of GLP-1 RA with demon- rences of hypoglycemia (aware or un- Recommendation 8.25 was revised to strated benefits in individuals with type 2 aware), and high glycemic variability emphasize use of a CGM device to im- diabetes, symptomatic heart failure with should be used. prove safety in individuals with post– preserved ejection fraction, and obesity. Tables 9.3 and 9.4 were updated with metabolic surgery hypoglycemia. Recommendation 9.13 was revised to glucose-lowering medication and insulin Updated Tables 8.1 and 8.2 provide recommend use of either SGLT2 inhibi- costs as of 1 July 2024, and an expanded detailed information on the efficacy, com- tor or GLP-1 RA with demonstrated ben- discussion on medication costs and afford- mon side effects, safety considerations, efits in individuals with type 2 diabetes ability was added to the text. and costs of approved weight manage- and CKD. In the new subsection “Special Circum- ment pharmacotherapy options. Recommendations 9.15 and 9.16 were stances and Populations,” Recommenda- Downloaded from http://diabetesjournals.org/care/article-pdf/48/Supplement_1/S6/791587/dc25srev.pdf by guest on 23 December 2024 Discussion of medication cost and ac- added to recommend treatment of indi- tions 9.31a, 9.31b, and 9.31c were added cess barriers was added to the text, in- viduals with type 2 diabetes and MASLD to advise on actions to take when medica- cluding suggestions to members of the or MASH with GLP-1 RA, dual GIP and tions are not available (such as medication interprofessional diabetes care team on GLP-1 RA, pioglitazone, or a combination shortages); Recommendations 9.32a and mitigating financial barriers. of GLP-1 RA and pioglitazone based on 9.32b were added to address care consid- the staging of liver disease risk and need erations for individuals of childbearing po- Section 9. Pharmacologic for weight management. tential; and Recommendation 9.33 was Approaches to Glycemic Treatment Figure 9.3 and the text discussing added to provide guidance on mitigating (https://doi.org/10.2337/dc25-S009) choice of glucose-lowering therapy in risk of ketoacidosis when individuals at This section was reorganized and ex- adults with type 2 diabetes were exten- risk for ketoacidosis or who follow a keto- panded with two new subsections: 1) a sively revised to facilitate evidence-based genic eating pattern are treated with SGLT subsection titled “Additional Recommen- selection of glucose-lowering therapies inhibition. Additional text in this subsec- dations for All Individuals With Diabetes” based on individualized treatment goals. tion discusses considerations for glucose- that includes new recommendations as Considerations of glucose-lowering medica- lowering pharmacotherapy for individuals well as recommendations previously listed tion effects on MASLD and MASH were with diabetes secondary to chemotherapy with those for individuals with type 1 or added to Fig. 9.3. and with other types of diabetes (i.e., type 2 diabetes if pertinent to individuals Table 9.2 was simplified and revised pancreatogenic diabetes, cystic fibrosis– regardless of their type of diabetes, and 2) to better highlight important considera- related diabetes, posttransplant diabetes, a subsection titled “Special Circumstances tions when choosing medications for maturity-onset diabetes of the young, and Populations.” lowering glucose in type 2 diabetes. and neonatal diabetes). Figure 9.1 was revised for clarity, and a Recommendation 9.20 was clarified to general statement was added to Table 9.1 recommend reassessing the need for and/or Section 10. Cardiovascular Disease on dose adjustments when using AID dose of medications with higher hypogly- and Risk Management systems. cemia risk (i.e., sulfonylureas, meglitinides, (https://doi.org/10.2337/dc25-S010) The subsection on insulin administra- and insulin) when initiating a new glucose- Recommendation 10.1 was updated with tion technique was expanded to address lowering medication to minimize the risk details on the frequency of recommended inhaled insulin and use of insulin bolus of hypoglycemia and treatment burden. blood pressure monitoring. patches. Recommendation 9.21 was added to Figure 10.2 was updated to provide Recommendation 9.8 was revised to advise against concurrent use of a dipep- clarity on medication classes for the emphasize the importance of selecting tidyl peptidase 4 inhibitor with a GLP-1 treatment of confirmed hypertension in glucose-lowering medications that pro- RA due to lack of additional glucose low- nonpregnant people with diabetes. vide sufficient effectiveness and achieve ering beyond that of a GLP-1 RA alone. Recommendation 10.12 was modified and maintain multiple treatment goals Recommendation 9.24 was clarified by to specify appropriate monitoring for in- simultaneously, including improving car- specifying that a GLP-1 RA or a dual GIP creased serum creatinine levels, serum diovascular, kidney, weight, and other and GLP-1 RA is preferred to insulin in potassium levels, and hypokalemia when relevant outcomes, reducing hypoglyce- adults with type 2 diabetes only in the ab- ACE inhibitors, angiotensin receptor block- mia risk, and considering cost, access, sence of evidence of insulin deficiency. ers (ARBs), or mineralocorticoid receptor risk for adverse reactions, and individual Text in the “Basal Insulin” section was re- antagonists are used. preferences. vised to provide guidance on switching be- Recommendation 10.13 was added to Recommendations were revised to ex- tween different basal insulin formulations. specify hypertension treatment options that plicitly advise on choice of pharmacother- Figure 9.4 was revised for clarity, and should be avoided during pregnancy and in apy for individuals with type 2 diabetes and the list of options for prandial insulin was sexually active individuals of childbearing established or high risk of atherosclerotic expanded. potential not using reliable contraception. cardiovascular disease (ASCVD) (Recom- Recommendation 9.27 was revised to Recommendation 10.26 was added to mendation 9.10), heart failure (Recommen- remove consideration of basal insulin recommend that in most cases lipid- dation 9.11), and chronic kidney disease doses exceeding 0.5 units/kg/day as evi- lowering agents should be discontinued (CKD) (Recommendation 9.12) to improve dence of overbasalization. Instead, signs prior to conception and avoided in sexually diabetesjournals.org/care Summary of Revisions S11 active individuals of childbearing potential ACE inhibitors, ARBs, or mineralocorti- individuals who smoke and have a prior not using reliable contraception, unless the coid receptor antagonists are used. history of lower-extremity complications, benefits may outweigh the risk. Recommendation 11.5b was updated loss of protective sensation, structural ab- Figures 10.3 and 10.4 were added to to state that for people with type 2 diabe- normalities, or PAD. illustrate recommendations for primary tes and CKD, a GLP-1 RA with demon- Increasing role of surgery in diabetic prevention and secondary prevention of strated benefit in this population should foot management was added to the ASCVD, respectively, in people with dia- be used to reduce cardiovascular risk and narrative text of foot care section. betes using cholesterol-lowering therapy. kidney disease progression. Triglyceride thresholds were updated Recommendation 11.6 was added to Section 13. Older Adults in Recommendations 10.31 and 10.32. state that potentially harmful antihyper- (https://doi.org/10.2337/dc25-S013) The criteria for coronary artery disease tensive medications in pregnancy should The 4Ms framework of age-friendly health investigations in Recommendation 10.39b be avoided in sexually active individuals of systems (Mentation, Medications, Mobil- were revised to include signs or symptoms childbearing potential not using reliable Downloaded from http://diabetesjournals.org/care/article-pdf/48/Supplement_1/S6/791587/dc25srev.pdf by guest on 23 December 2024 ity, and What Matters Most) as it applies of cardiac or associated vascular disease contraception and to switch to options to diabetes management in older adults or electrocardiogram abnormalities. considered safer prior to conception and was introduced and illustrated in the new Recommendation 10.41 was modified during pregnancy. Fig. 13.1. to include screening for peripheral artery Recommendation 11.7 was updated Recommendation 13.8a was modified disease (PAD) with ankle-brachial index to specify reducing urinary albumin by to include time in range and time below testing in asymptomatic people with diabe- $30% to slow progression of CKD. range in addition to A1C treatment goals tes aged $65 years, microvascular disease Recommendation 11.8 was updated to for older adults who are otherwise healthy in any location, or foot complications or specify protein goals for individuals with with few and stable chronic conditions any end-organ damage from diabetes if a stage 3 or higher CKD and those who are and intact cognitive functional status. PAD diagnosis would change management. treated with dialysis. Recommendation 13.8b was modified PAD screening should also be considered in Table 11.1 was added to include rea- to include time in range and time below individuals with diabetes duration $10 years sons to consider non–diabetes-related kid- range in addition to A1C treatment goals and high cardiovascular risk. ney diseases in a person with CKD and for older adults who have intermediate or For individuals with type 2 diabetes, diabetes, and Table 11.3 was added to in- complex health who are clinically hetero- obesity, and symptomatic heart failure clude suggestions for interventions that geneous with variable life expectancy. with preserved ejection fraction, Recom- lower albuminuria. Table 13.1 was modified to include a mendation 10.46d was added to recom- column on reasonable CGM goals for each mend treatment with a GLP-1 RA with Section 12. Retinopathy, Neuropathy, health status category. demonstrated benefit in this population and Foot Care (https://doi.org/10.2337/dc25-S012) In the “Treatment” section, the appro- to reduce heart failure–related symptoms, Recommendation 12.5 was updated to priate selection and use of SGLT2 inhibi- reduce physical limitations, and improve exercise function. specify involvement of an ophthalmol- tors in older adults was expanded. Figure 10.5 was added to illustrate rec- ogist for more frequent examinations ommendations for screening for asymp- if retinopathy is progressing or sight Section 14. Children and Adolescents tomatic and undiagnosed cardiovascular threatening. (https://doi.org/10.2337/dc25-S014) disease, and Fig. 10.6 was added to pro- Recommendation 12.8 wording was Recommendation 14.4 in the “Type 1 vide an overview of recommendations for changed to reflect that a dilated eye exam Diabetes” section was added to empha- the prevention of the development of should be performed before and in the first size key nutrition principles. symptomatic heart failure in people with trimester, rather than one or the other. Recommendation 14.10 was altered to diabetes. Recommendation 12.19 was modified emphasize limits on sedentary activity. to include additional screening criteria Recommendation 14.21 was changed Section 11. Chronic Kidney Disease for symptoms and signs of autonomic to state that insulin pumps should be of- and Risk Management neuropathy. fered to anyone with type 1 diabetes who (https://doi.org/10.2337/dc25-S011) Recommendation 12.22 was updated can use the devices safely. Recommendation 11.3 was amended to recommend against opioid use for neu- Recommendation 14.24 was modified for clarity about optimizing blood pres- ropathic pain treatment due to the poten- to remove lack of access as a reason for sure management goals. tial for adverse events, and the narrative less stringent A1C goals. Recommendation 11.4a was revised to text was updated to expand on this. Recommendation 14.26 was altered to clarify that ACE inhibitors or ARBs should A short discussion on the role of weight include weight gain as a balancing mea- be titrated to the maximally tolerated dose management and neuropathy was added sure for more stringent A1C goals. to prevent the progression of CKD and re- to the narrative text. Recommendation 14.36 was changed to duce cardiovascular events in nonpregnant Recommendation 12.24 was updated exclude secondary causes of hypertension. individuals with diabetes and hypertension. to include the Ipswich touch test as an Recommendation 14.41 was updated Recommendation 11.4b was modified option for neurological assessment. to include the use of age-approved statins. to specify appropriate monitoring for in- Recommendation 12.29 was expanded Recommendation 14.50 was modified creased serum creatinine levels, serum to include the importance of smoke cessa- to state that screening should be re- potassium levels, and hypokalemia when tion and referral for counseling for peated at a minimum of 2-year intervals S12 Summary of Revisions Diabetes Care Volume 48, Supplement 1, January 2025 or more frequently if screening is nor- Recommendation 15.7 wording was The narrative for subsection “Physical mal and BMI is increasing. changed to reflect that a dilated eye exam Activity” includes recommended activity Recommendation 14.57 was revised should be performed before and in the first levels for pregnancy, as these pertain to to include the key nutritional principles trimester, rather than one or the other. individuals with any type of diabetes in and provide specific examples of healthy Table 15.1 was updated with a folic pregnancy. food choices and what foods should be acid supplement recommendation of The “Insulin” subsection includes in- avoided. 400–800 mg/day and clarification for formation on different insulin delivery Recommendation 14.60 was changed which checklist items are only for indi- modalities used during labor and deliv- to recommend an A1C goal of