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

ADA Guidelines for Diabetes Management

Foundation: Universal Starting Point for All Patients

All adults with diabetes must immediately begin comprehensive lifestyle modifications including diabetes self-management education, medical nutrition therapy, at least 150 minutes weekly of moderate-intensity aerobic activity, and resistance training twice weekly, as these interventions reduce A1C by 0.3-2% and lower mortality risk regardless of medication use. 1, 2, 3

• Diabetes self-management education and support reduces mortality risk and healthcare costs with high-quality evidence and must be provided at diagnosis and continuously throughout care 1, 2
• Medical nutrition therapy delivered by a registered dietitian reduces A1C by 0.3-2% in type 2 diabetes and 1.0-1.9% in type 1 diabetes 1, 2, 3
• Physical activity prescription: 150 minutes per week of moderate-intensity aerobic exercise spread over at least 3 days with no more than 2 consecutive days without activity, plus resistance training 2-3 sessions per week on nonconsecutive days 2
• Weight loss: Minimum 5% body weight reduction is mandatory for all overweight/obese patients with type 2 diabetes before or concurrent with pharmacotherapy 1, 2, 3

Nutrition Specifics

• Limit saturated fat to 7% of total calories and minimize trans fat intake 4
• Lower dietary cholesterol to 200 mg/day 4
• Consume two or more servings of fish per week (except commercially fried fish) for omega-3 fatty acids 4
• Usual protein intake (15-20% of energy) does not need modification in patients with normal renal function 4
• If adults choose to use alcohol, limit to one drink per day or less for women and two drinks per day or less for men, consumed with food to reduce nocturnal hypoglycemia risk 4

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Type 2 Diabetes: Pharmacologic Algorithm

Metformin is the mandatory first-line agent at or soon after diagnosis due to efficacy, safety, low cost, cardiovascular benefits, and mortality reduction. 1, 2, 3

• Start metformin 500 mg twice daily with meals, increasing to 1000 mg twice daily over 2-4 weeks to minimize gastrointestinal side effects 3

Immediate Add-On Therapy for High-Risk Patients

For patients with established atherosclerotic cardiovascular disease, heart failure, or chronic kidney disease at diagnosis, immediately add an SGLT2 inhibitor or GLP-1 receptor agonist with proven cardiovascular benefit alongside metformin. 1, 2

• For heart failure: Add SGLT2 inhibitor for glycemic management and prevention of heart failure hospitalizations 2
• For chronic kidney disease: Add SGLT2 inhibitor to minimize CKD progression, reduce cardiovascular events, and reduce heart failure hospitalizations 2
• For advanced CKD: Add GLP-1 receptor agonist (preferred over SGLT2 inhibitor) for glycemic management due to lower hypoglycemia risk and cardiovascular event reduction 2

Treatment Intensification

If metformin monotherapy at maximum tolerated dose does not achieve HbA1c target after 3 months, add a second agent immediately. 1, 3

• Choose from six evidence-based options: sulfonylureas, thiazolidinediones, DPP-4 inhibitors, SGLT2 inhibitors, GLP-1 agonists, or basal insulin based on patient-specific factors 3
• GLP-1 receptor agonists are the first injectable medication before insulin 1

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Type 1 Diabetes: Insulin-Based Management

Patients with type 1 diabetes require multiple daily insulin injections (≥3 injections daily) or continuous subcutaneous insulin infusion from diagnosis. 1, 2, 3

• Insulin analogues must be used instead of regular human insulin to significantly reduce hypoglycemia risk 1, 2, 3
• Automated insulin delivery systems should be considered for all adults with type 1 diabetes 2
• Patients must receive education on matching mealtime insulin doses to carbohydrate content, preprandial glucose levels, and anticipated physical activity 2, 3
• For individuals using rapid-acting insulin by injection or pump, adjust meal and snack insulin doses based on carbohydrate content 4
• For individuals using fixed daily insulin doses, keep carbohydrate intake consistent day-to-day with respect to time and amount 4

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Glycemic Targets and Monitoring

Target HbA1c <7% for most patients to reduce microvascular complications. 1, 3

• More stringent targets (6.0-6.5%) are appropriate for select patients when achievable without increased hypoglycemia risk 1
• Check HbA1c every 3 months until target is achieved, then every 6 months 1, 3
• Do not aggressively pursue near-normal HbA1c levels in patients with advanced disease, limited life expectancy, or hypoglycemia unawareness as this increases mortality risk without benefit 3

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Hypoglycemia Management

Treat hypoglycemia (glucose <70 mg/dL) with 15-20 grams of rapid-acting glucose, preferably pure glucose. 1, 2, 3

• Confirm blood glucose reversal with self-monitoring after 15 minutes; if hypoglycemia persists, repeat treatment 1, 3
• Glucagon must be prescribed for all individuals taking insulin or at high risk for hypoglycemia; family and caregivers must know its location and administration 2
• Severe or frequent hypoglycemia is an absolute indication for treatment regimen modification 1, 2, 3

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Cardiovascular Risk Management

Lipid Management

Initiate at least moderate-intensity statin therapy for most patients with diabetes aged 40 years or older to reduce cardiovascular mortality. 4, 1, 2, 3

• Obtain lipid profile at diabetes diagnosis, at initial medical evaluation, and every 5 years thereafter (or more frequently if indicated) 4
• Target LDL cholesterol <100 mg/dL, HDL cholesterol >40 mg/dL (>50 mg/dL for women), and triglycerides <150 mg/dL 4
• For patients not at LDL goal, start pharmacological therapy at LDL ≥130 mg/dL with goal of <100 mg/dL 4
• Consider adding ezetimibe to moderate-intensity statin therapy for patients with recent acute coronary syndrome and LDL ≥50 mg/dL or those intolerant to high-intensity statins 4, 3
• Combination therapy with statin and fibrate has not been shown to improve cardiovascular outcomes and is generally not recommended 4

Triglyceride Management

• Improve glycemic control aggressively for elevated triglycerides, as this can be very effective 4
• Above 400 mg/dL, give strong consideration to pharmacological treatment to minimize risk of pancreatitis 4
• For triglycerides ≥500 mg/dL, evaluate for secondary causes and consider medical therapy to reduce pancreatitis risk 4

Blood Pressure Management

Target blood pressure <140/90 mm Hg for patients with diabetes and hypertension. 4, 1, 2, 3

• Measure blood pressure at every routine visit; confirm elevated readings on a separate day 4
• Initiate ACE inhibitor or ARB (but not both) as first-line antihypertensive therapy for renal protection 4, 2, 3
• If one class is not tolerated, substitute the other 4
• Multidrug therapy is generally required to achieve blood pressure targets 4
• Monitor serum creatinine/eGFR and potassium levels when using ACE inhibitors, ARBs, or diuretics 4

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Screening for Complications

Arrange annual comprehensive dilated eye examination by an ophthalmologist or optometrist starting immediately at diagnosis. 1, 2, 3

• Assess cardiovascular risk factors annually including dyslipidemia, hypertension, smoking, family history of premature coronary disease, and presence of albuminuria 4, 1, 3
• Annual comprehensive foot examination including visual inspection for skin integrity, callous formation, deformities, or ulcers 2
• Annual laboratory monitoring: lipid profile, spot urinary albumin-to-creatinine ratio, serum creatinine and eGFR, liver function tests, thyroid-stimulating hormone, vitamin B12 levels, and serum potassium 2

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Critical Pitfalls to Avoid

• Never delay intensification of therapy when glycemic targets are not met within 3 months 1, 3
• Never aggressively lower blood pressure below 130/70 mm Hg in older adults due to increased mortality risk 4, 1, 3
• Never continue aggressive glycemic targets in patients experiencing severe or frequent hypoglycemia as this is an absolute indication for regimen modification 1, 2, 3
• Never delay adding SGLT2 inhibitor or GLP-1 receptor agonist in patients with established cardiovascular disease, heart failure, or chronic kidney disease 1, 2
• Never neglect ongoing lifestyle modifications throughout the entire treatment course regardless of medication regimen 1, 2, 3
• Never use protein to treat acute or prevent nighttime hypoglycemia in type 2 diabetes, as ingested protein increases insulin response without increasing plasma glucose 4
• Never use ACE inhibitors and ARBs together, as this combination does not improve outcomes 4