What are the 2025 American Diabetes Association (ADA) guidelines for managing diabetes?

2025 American Diabetes Association Guidelines for Managing Diabetes

The 2025 American Diabetes Association (ADA) guidelines emphasize a person-centered shared decision-making approach to diabetes management that prioritizes cardiovascular and renal outcomes, effectiveness, hypoglycemia risk, weight management, and individual preferences. 1, 2

Glycemic Targets

• A1C goal of <7% (<53 mmol/mol) is recommended for most non-pregnant adults with diabetes 1
• Preprandial glucose target: 80-130 mg/dL (4.4-7.2 mmol/L)
• Postprandial glucose target: <180 mg/dL (<10.0 mmol/L) 1

Individualized A1C Targets:

• More stringent targets (<6.5%) for selected individuals without significant hypoglycemia risk or burden of care 1
• Less stringent targets (<7.5%) for those who cannot articulate hypoglycemia symptoms, have hypoglycemia unawareness, or lack advanced monitoring technology 1
• Even less stringent targets (<8%) for those with history of severe hypoglycemia, limited life expectancy, or when treatment harms outweigh benefits 1

Pharmacologic Approach to Glycemic Management

First-Line Therapy

• Metformin remains first-line therapy at diagnosis unless contraindicated 2

Medication Plan Evaluation

• Medication plans should be reevaluated every 3-6 months and adjusted as needed 1
• Early combination therapy should be considered to shorten time to goal attainment 1

Second-Line Agents Based on Comorbidities

1. For patients with heart failure: SGLT2 inhibitor is recommended regardless of ejection fraction 1
2. For patients with CKD (eGFR 20-60 mL/min/1.73m²): SGLT2 inhibitor is recommended to minimize CKD progression 1
3. For patients with advanced CKD (eGFR <30 mL/min/1.73m²): GLP-1 RA is preferred for glycemic management 1
4. For weight management goals: Choose agents that support weight loss 1

Insulin Therapy

• Consider insulin regardless of background therapy if there is:
  • Evidence of ongoing catabolism (unexpected weight loss)
  • Symptoms of hyperglycemia
  • Very high A1C (>10%) or blood glucose (≥300 mg/dL) 1
• GLP-1 RA is preferred to insulin when possible 1
• If insulin is used, combine with GLP-1 RA for greater effectiveness, weight benefits, and lower hypoglycemia risk 1

Cardiovascular Disease and Risk Management

• Screen for asymptomatic heart failure with BNP or N-terminal pro-BNP; echocardiography is recommended for those with abnormal BNP levels 1
• Screen for peripheral artery disease in individuals with diabetes who are ≥65 years, have microvascular disease, foot complications, or end-stage organ damage 1
• For patients with established ASCVD or high CV risk: Add SGLT2 inhibitor or GLP-1 RA with proven cardiovascular benefit 2

Monitoring Recommendations

• A1C testing: At least twice yearly for stable patients, quarterly if not meeting targets 2
• CGM metrics: Time in range (70-180 mg/dL), time below range (<70 mg/dL and <54 mg/dL), and time above range (>180 mg/dL and >250 mg/dL) should be used alongside A1C 1
• Regular monitoring of blood pressure, lipids, weight, and kidney function 2

Hypoglycemia Management

• Treat hypoglycemia with 15-20g of glucose (preferred) or carbohydrates
• Recheck blood glucose after 15 minutes; repeat treatment if hypoglycemia persists
• Prescribe glucagon for all individuals at significant risk of severe hypoglycemia 2

Lifestyle Recommendations

• Physical activity: At least 150 minutes of moderate-intensity aerobic activity weekly, plus 2-3 sessions of resistance exercise per week 2
• Weight management: Aim for 7-10% weight loss if overweight or obese 2
• Nutrition therapy: Focus on non-starchy vegetables, whole fruits, legumes, whole grains, nuts and seeds, and low-fat dairy products; minimize red meat, sugar-sweetened beverages, sweets, refined grains, and processed foods 2

Chronic Care Model Implementation

The ADA recommends implementing the Chronic Care Model with six core elements:

1. Proactive care delivery system with team-based approach
2. Self-management support
3. Evidence-based decision support
4. Clinical information systems using registries
5. Community resources and policies supporting healthy lifestyles
6. Health systems with quality-oriented culture 1

Special Populations

Children and Adolescents

• CGM or intermittently scanned CGM should be offered at diagnosis or as soon as possible 1
• Automated insulin delivery (AID) systems should be offered to those capable of using them safely 1
• A1C goal <7% is recommended, particularly when parents/caregivers and child jointly perform diabetes-related tasks 1

Pitfalls and Caveats

• Overbasalization with insulin therapy: Watch for basal dose >0.5 units/kg/day, high bedtime-morning glucose differential, hypoglycemia, and high glycemic variability 1
• SGLT2 inhibitor glycemic benefits are reduced at eGFR <45 mL/min/1.73 m² despite continued cardio-renal benefits 1
• Factors affecting A1C accuracy: Conditions affecting red blood cell turnover (hemolytic anemia, G6PD deficiency, recent blood transfusion, erythropoiesis-stimulating drugs, end-stage kidney disease, pregnancy) can interfere with A1C measurement 1
• A1C cannot be measured in individuals with homozygous hemoglobin variants (HbSS, HbEE) 1

The 2025 ADA guidelines represent an evolution in diabetes care that emphasizes individualized treatment approaches while prioritizing cardiovascular and renal outcomes alongside glycemic control.