What are the updates in type 1 diabetes management in the 2026 guideline?

What's New in Type 1 Diabetes Management: 2025 ADA Guidelines

Automated insulin delivery (AID) systems should now be offered to ALL adults with type 1 diabetes as the preferred insulin delivery method—this represents a major shift from previous recommendations where AID was merely "considered" to now being the standard of care. 1

Major Updates in the 2025 Guidelines

Automated Insulin Delivery Systems - The Game Changer

The most significant change is the elevation of AID systems from optional to standard therapy. The 2025 guidelines now state that AID systems should be offered to all adults with type 1 diabetes, not just considered as an option. 1 This recommendation carries an "A" level of evidence, reflecting strong clinical trial data demonstrating superior glycemic control with reduced hypoglycemia compared to sensor-augmented pumps or multiple daily injections. 1

Key distinction from 2023: The 2023 guidelines stated AID systems "may be considered" for capable individuals 1, while 2025 guidelines now recommend they "should be offered" to all adults with type 1 diabetes as the preferred method. 1

Continuous Glucose Monitoring as Standard of Care

Early use of CGM is now explicitly recommended for adults with type 1 diabetes immediately after diagnosis, not just for those with specific indications. 1 The guidelines emphasize that CGM integration "soon after diagnosis" improves glycemic outcomes, decreases hypoglycemic events, and improves quality of life. 1 This represents a shift from selective use to universal recommendation.

Insulin Analog Preference Strengthened

The 2025 guidelines maintain but strengthen the recommendation that insulin analogs (or inhaled insulin) are preferred over injectable human insulins to minimize hypoglycemia risk, with an "A" level recommendation. 1 This applies to both prandial and basal insulin formulations.

Enhanced Patient Education Requirements

The guidelines now explicitly include education on fat and protein intake adjustment, not just carbohydrate counting. 1 Patients should be taught to modify insulin doses based on:

• Carbohydrate intake
• Fat and protein content of meals (new emphasis)
• Concurrent glycemia
• Glycemic trends from CGM
• Sick-day management
• Anticipated physical activity 1

This represents a more sophisticated approach to prandial insulin dosing beyond simple carbohydrate counting.

Insulin Administration Technique Updates

The 2025 guidelines provide expanded guidance on proper insulin administration technique, including:

• Specific emphasis on avoiding intramuscular injection, which causes unpredictable absorption and frequent unexplained hypoglycemia 1
• Recognition that risk for IM delivery is increased in younger, leaner individuals when injecting into limbs rather than truncal sites (abdomen and buttocks) 1
• Explicit recommendation for injection site rotation to prevent lipohypertrophy 1
• Guidance on proper use of connected insulin pens for those on multiple daily injections 1

Technology Integration Recommendations

Connected insulin pens should now be offered to people with diabetes taking multiple daily insulin injections. 1 This represents recognition of the value of data integration and dose tracking even for those not using pumps.

FDA-approved insulin dose calculators/decision support systems may be helpful for calculating insulin doses, representing acknowledgment of digital health tools. 1

What Remains Unchanged But Reinforced

Core Insulin Therapy Approach

• Most adults with type 1 diabetes should receive continuous subcutaneous insulin infusion OR multiple daily doses of prandial and basal insulin (Level A recommendation) 1
• Total daily insulin typically 0.4-1.0 units/kg/day, split approximately 50% basal and 50% prandial 2, 3

Monitoring Schedule

• Insulin treatment plans should be reevaluated every 3-6 months 1

Glycemic Targets

• A1C <7% for most nonpregnant adults 2
• Preprandial glucose 90-130 mg/dL 2
• Peak postprandial glucose <180 mg/dL 2

Clinical Implementation Algorithm

For newly diagnosed adults with type 1 diabetes:

1. Initiate CGM immediately at diagnosis 1

2. Offer AID system as first-line therapy if patient is capable of using the device safely 1

   • If AID not feasible: Consider insulin pump with CGM 1
   • If pump not feasible: Multiple daily injections with insulin analogs plus CGM 1

3. Start with insulin analogs exclusively—avoid human insulins 1

   • Rapid-acting analogs (aspart, lispro, glulisine) for prandial coverage 2, 3
   • Long-acting analogs for basal coverage 2, 3

4. Provide comprehensive education on carbohydrate counting PLUS fat and protein adjustment 1

5. Prescribe glucagon (preferably non-reconstitution formulation) and educate caregivers 2, 3

6. Reassess every 3-6 months and adjust therapy 1

Common Pitfalls to Avoid

Don't delay AID system discussion: The 2025 guidelines make clear this should be offered to all adults, not reserved for those "failing" other therapies. 1

Don't use human insulins when analogs are available: The hypoglycemia risk reduction with analogs is well-established and now carries an "A" recommendation. 1

Don't limit education to carbohydrate counting alone: Fat and protein content significantly impacts postprandial glucose and should be incorporated into dosing education. 1

Don't inject into limbs in lean patients: This increases risk of intramuscular injection with unpredictable absorption—use truncal sites (abdomen, buttocks) instead. 1

Don't wait to start CGM: Early integration improves outcomes and is now standard of care from diagnosis. 1