What are the American Diabetic Association's (ADA) 2025 guidelines for managing diabetes?

American Diabetes Association 2025 Guidelines for Managing Diabetes

The ADA 2025 Standards of Care prioritize individualized glycemic targets with HbA1c <7% (53 mmol/mol) for most non-pregnant adults, metformin as first-line therapy for type 2 diabetes, and insulin for type 1 diabetes, with increasing emphasis on technology integration including continuous glucose monitoring and automated insulin delivery systems. 1, 2

Glycemic Targets and Goals

Standard Targets for Non-Pregnant Adults

• Target HbA1c <7% (53 mmol/mol) for most non-pregnant adults with diabetes to reduce microvascular complications and mortality 2
• More stringent target of HbA1c <6.5% (48 mmol/mol) for patients with short diabetes duration, type 2 diabetes managed with lifestyle or metformin only, long life expectancy, or no significant cardiovascular disease 2
• Less stringent target of HbA1c <8% (64 mmol/mol) for patients with severe hypoglycemia history, limited life expectancy, advanced complications, extensive comorbidities, or difficult-to-control long-standing diabetes 2

Pregnancy-Specific Targets

• Fasting glucose 70-95 mg/dL (3.9-5.3 mmol/L) 1
• One-hour postprandial glucose 110-140 mg/dL (6.1-7.8 mmol/L) OR two-hour postprandial glucose 100-120 mg/dL (5.6-6.7 mmol/L) 1
• Target A1C <6% to <7% (42-53 mmol/mol) early in gestation, accounting for hypoglycemia risk 1

Hypoglycemia Definitions and Management

• Level 1: glucose <70 mg/dL (3.9 mmol/L) - treat with fast-acting carbohydrates 2
• Level 2: glucose <54 mg/dL (3.0 mmol/L) - requires immediate treatment 2
• Level 3: altered mental/physical status requiring assistance - may require glucagon 2

Initial Management of Newly Diagnosed Diabetes

Diagnostic Assessment

• Check for ketosis/ketoacidosis, random blood glucose, and A1C levels to determine diabetes type and severity 3
• Test for pancreatic autoantibodies to differentiate type 1 from type 2 diabetes 3

Treatment Algorithm Based on Presentation

For severe hyperglycemia (A1C ≥8.5% or random glucose ≥250 mg/dL with symptoms, or ketosis/ketoacidosis present):

• Initiate insulin therapy immediately at 0.5 units/kg/day basal insulin, titrating based on blood glucose monitoring 3
• Add metformin after ketosis resolves, titrating to 2,000 mg daily as tolerated 3

For metabolically stable patients:

• Start metformin as first-line therapy, titrating to 2,000 mg per day as tolerated 1, 3
• Metformin is contraindicated with eGFR <30 mL/min/1.73 m² 1
• Monitor for vitamin B12 deficiency with chronic metformin use 1

Type 1 Diabetes Management

Insulin Delivery Systems

• Automated insulin delivery (AID) systems are preferred for individuals with type 1 diabetes capable of using the device safely to improve time in range, reduce A1C, and decrease hypoglycemia 1
• Continuous subcutaneous insulin infusion (CSII) via pump therapy combined with CGM should be considered whenever feasible 1
• Total daily insulin requirements typically range from 0.4 to 1.0 units/kg/day, with approximately 30-50% as basal and remainder as prandial 1

Insulin Dosing Strategy

• Starting dose of 0.5 units/kg/day is typical for metabolically stable adults with type 1 diabetes 1
• Lower doses (0.2-0.6 units/kg) for young children and those with continued endogenous insulin production during honeymoon period 1
• Adjust prandial insulin based on carbohydrate intake, premeal glucose levels, anticipated activity, and sick-day management 1

Type 2 Diabetes Pharmacologic Management

First-Line Therapy

• Metformin remains first-line for metabolically stable patients with type 2 diabetes 1, 3
• Start metformin and titrate to 2,000 mg per day as tolerated 1

Combination Therapy When A1C ≥1.5% Above Goal

Prioritize organ protection over glucose lowering alone:

For patients with established atherosclerotic cardiovascular disease (ASCVD):

• Add GLP-1 receptor agonist with proven cardiovascular benefit OR SGLT2 inhibitor with proven cardiovascular benefit 1

For patients with heart failure or chronic kidney disease:

• Add SGLT2 inhibitor with evidence for heart failure or kidney disease benefit 1

For patients requiring weight management:

• Add GLP-1 receptor agonist (including dual GIP/GLP-1 agonists) with highest efficacy for weight reduction 1

Severe Hyperglycemia Management

• For blood glucose ≥300 mg/dL (≥16.7 mmol/L) or A1C >10% (>86 mmol/mol) with symptoms or catabolism, initiate insulin therapy 1
• Alternative: sulfonylurea, GLP-1 RA, or dual GIP/GLP-1 RA can be effective, though evidence is limited for baseline A1C >10-12% 1

Children and Adolescents with Diabetes

Type 2 Diabetes in Youth

• Initial treatment with metformin when insulin not required; metformin alone provides durable glycemic control in approximately 50% of youth 1
• GLP-1 receptor agonists are safe and effective for decreasing A1C in youth, though gastrointestinal side effects are more frequent 1
• Empagliflozin 10 mg demonstrated significant A1C reduction (0.84% vs placebo) in youth aged 10-17 years with type 2 diabetes 1
• Avoid GLP-1 receptor agonists in individuals with family history of medullary thyroid cancer 1

Insulin Pump Therapy Considerations

• May be considered for youth on long-term multiple daily injections who can safely manage the device 1

Technology Integration

Continuous Glucose Monitoring (CGM)

• CGM should be used in concordance with appropriate time in range (TIR) targets to reduce hypoglycemia and glycemic variability 1
• Real-time CGM or intermittently scanned CGM provides assessment of glycemic control and aids insulin dose adjustment 1
• CGM combined with artificial intelligence enhances insulin delivery accuracy and predicts hypo- or hyperglycemia 1

Automated Insulin Delivery Systems

• AID systems integrate CGM data, control algorithm, and insulin pump to automate subcutaneous insulin delivery 1
• AID systems are preferred over sensor-augmented pump therapy for increased time in range and reduction of hypoglycemia 1

Pregnancy Management

Insulin Physiology Changes

• Early pregnancy (before 16 weeks): enhanced insulin sensitivity, lower insulin requirements, increased hypoglycemia risk 1
• After 16 weeks: insulin resistance increases linearly through week 36, typically doubling daily insulin dose compared to prepregnancy 1
• Rapid reduction in insulin requirements may indicate placental insufficiency 1

Monitoring Strategy

• Fasting and postprandial blood glucose monitoring recommended to achieve metabolic control 1
• Postprandial monitoring associated with better glycemic outcomes and lower preeclampsia risk 1
• Preprandial testing recommended when using insulin pumps or basal-bolus therapy 1

Prediabetes Management

Lifestyle Intervention Targets

• Weight loss ≥7% of initial body weight through intensive lifestyle behavior change programs 2
• Physical activity ≥150 minutes per week of moderate-intensity activity 2
• Reduced-calorie diet with 500-1,000 calories/day reduction, focusing initially on reducing total fat 2

Special Populations

Ramadan Fasting

• Prioritize pharmacologic therapies with low hypoglycemia risk profile 1
• CGM devices show promise for monitoring during fasting periods 1
• Patients with high ASCVD risk should avoid Ramadan fasting until more conclusive evidence available 1
• Counseling should begin 6-8 weeks prior to Ramadan start 1

Inpatient Management

• Random blood glucose >7.8 mmol/L (140 mg/dL) is threshold for diagnosing inpatient hyperglycemia 1
• Insulin therapy remains cornerstone of inpatient hyperglycemia management 1
• Non-insulin drugs can have a role in management of inpatients with type 2 diabetes 1

Common Pitfalls to Avoid

• Do not delay insulin initiation in patients with severe hyperglycemia, ketosis, or catabolic features 1, 3
• Do not continue metformin when eGFR falls below 30 mL/min/1.73 m² due to lactic acidosis risk 1
• Do not neglect vitamin B12 monitoring in patients on chronic metformin therapy 1
• Do not use GLP-1 receptor agonists in patients with family history of medullary thyroid cancer 1
• Do not aim for overly stringent targets in patients with hypoglycemia unawareness, limited life expectancy, or advanced complications 2