What are the current American Diabetes Association 2024 Standards of Care guidelines for diagnosing and managing diabetes across all ages and types?

Current American Diabetes Association 2024 Guidelines for Diabetes

The 2024 ADA Standards of Care provide comprehensive, evidence-based recommendations for diagnosing and managing diabetes across all populations, with emphasis on cardiovascular and kidney risk reduction, individualized glycemic targets, and addressing social determinants of health. 1

Diagnosis and Screening

Diagnostic Criteria

• Perform A1C testing on all hospitalized patients with diabetes or hyperglycemia (random glucose >140 mg/dL) if no result is available from the prior 3 months. 1
• A1C ≥6.5%, fasting plasma glucose ≥126 mg/dL, or 2-hour oral glucose tolerance test ≥200 mg/dL confirms diabetes diagnosis 2
• HbA1c testing is now recommended by the ADA as an alternative to oral glucose tolerance testing for screening 3

Screening Recommendations

• Screen adults aged ≥65 years for cognitive impairment at initial visit, annually, and as appropriate, as older adults with diabetes face higher risk of cognitive decline and institutionalization. 1
• Screen for geriatric syndromes (cognitive impairment, depression, urinary incontinence, falls, persistent pain, frailty) and polypharmacy in older adults, as these affect self-management and quality of life 1

Glycemic Management

Pharmacologic Therapy Selection

Start pharmacologic therapy at diagnosis unless contraindicated, prioritizing agents that reduce cardiovascular and kidney disease risk in patients with established or high-risk ASCVD, heart failure, or chronic kidney disease. 1

First-Line Therapy

• Metformin remains initial medication for metabolically stable patients, starting at 500 mg once daily and titrating by 500 mg increments every 7 days to minimize gastrointestinal effects, with maximum dose of 2000 mg daily. 4
• For youth with A1C <8.5% without acidosis or ketosis, start metformin and titrate to 2000 mg daily as tolerated 4, 5

Intensification Strategy

• If A1C remains above goal after 3 months on maximum tolerated metformin, add a second agent—prioritize GLP-1 receptor agonist for patients with cardiovascular disease. 4
• Consider insulin as first injectable if symptoms of hyperglycemia are present, A1C >10%, or blood glucose ≥300 mg/dL, starting with 10 units per day or 0.1-0.2 units/kg per day 4
• Very high efficacy agents include high-dose dulaglutide, semaglutide, tirzepatide (dual GIP/GLP-1 RA), and insulin 1

Combination Therapy

• Continue glucose-lowering agents upon insulin initiation (unless contraindicated) for ongoing glycemic and metabolic benefits including weight, cardiometabolic, and kidney benefits. 1
• When starting insulin, reassess and reduce or discontinue agents with higher hypoglycemia risk (sulfonylureas and meglitinides) to minimize hypoglycemia and treatment burden 1
• When adding GLP-1 RA or dual GIP/GLP-1 RA, reassess insulin dosing upon addition or dose escalation 1

Monitoring and Adjustment

• Assess glycemic status at least every 3 months until target achieved. 6, 5
• Monitor for vitamin B12 deficiency with long-term metformin use, especially in patients with peripheral neuropathy 4
• Monitor for overbasalization during insulin therapy: basal dose exceeding 0.5 units/kg/day, significant bedtime-to-morning or postprandial-to-preprandial glucose differential, hypoglycemia occurrences, and high glycemic variability warrant prompt reevaluation. 1

Glycemic Targets

• Target HbA1c <7% for most adults with type 2 diabetes 6
• Targets should be individualized based on comprehensive assessment of medical, psychological, functional, and social domains in older adults 1

Cardiovascular Risk Management

Statin Therapy

For people with diabetes aged 40-75 years without ASCVD, use moderate-intensity statin therapy in addition to lifestyle therapy. 1

Primary Prevention (No ASCVD)

• Moderate-intensity statin therapy recommended for ages ≥40 years 1
• High-intensity statin therapy should be prescribed for patients with multiple ASCVD risk factors to reduce LDL cholesterol by ≥50% from baseline and target LDL <70 mg/dL (<1.8 mmol/L). 1
• High-intensity options: Atorvastatin 40-80 mg, Rosuvastatin 20-40 mg 1
• Moderate-intensity options: Atorvastatin 10-20 mg, Rosuvastatin 5-10 mg, Pravastatin 40-80 mg 1

Secondary Prevention (With ASCVD)

• High-intensity statin therapy is mandatory for all people with diabetes and ASCVD to target LDL cholesterol <70 mg/dL (<1.8 mmol/L), with optimal goal of LDL <55 mg/dL (<1.4 mmol/L) and >50% reduction from baseline. 1
• Add ezetimibe or PCSK9 inhibitor if goal not achieved on maximum tolerated statin therapy 1

Special Populations

• For type 1 diabetes or age <40 years, consider similar statin approaches particularly with other cardiovascular risk factors, despite limited trial evidence 1
• For statin-intolerant patients, bempedoic acid is recommended to reduce cardiovascular event rates as alternative cholesterol-lowering therapy. 1
• Statin therapy is contraindicated in pregnancy 1

Hospital Management

Inpatient Protocols

• Institutions must implement protocols using validated written or computerized provider order entry sets for dysglycemia management across all hospital settings (emergency department, ICU, non-ICU wards, gynecology-obstetrics/delivery units, dialysis suites, behavioral health units) allowing personalized approach. 1
• These protocols should include glucose monitoring, insulin and/or noninsulin therapy, hypoglycemia management, diabetes self-management education, and nutrition recommendations 1

Older Adults (≥65 Years)

Comprehensive Assessment

• Assess medical, psychological, functional (self-management abilities), and social domains to determine goals and therapeutic approaches for diabetes management. 1
• Screen for geriatric syndromes and polypharmacy as they affect self-management and diminish quality of life 1
• Screening for diabetes complications should be individualized and periodically revisited, as results impact treatment goals and approaches 1

Cognitive Function

• Over one-quarter of people over age 65 have diabetes, with higher rates of functional disability, accelerated muscle loss, and coexisting illnesses 1
• Certain glucose-lowering drugs (metformin, thiazolidinediones, GLP-1 receptor agonists) show small benefits on slowing cognitive dysfunction progression 1
• Blood pressure control and statin therapy are particularly important in older adults with diabetes due to association with reduced incident dementia risk. 1

Pediatric Considerations (Ages 10-17)

SGLT2 Inhibitors

• Empagliflozin is FDA-approved for children aged 10-17 years with type 2 diabetes, starting at 10 mg daily with potential escalation to 25 mg if A1C remains ≥7.0% after 12 weeks. 5
• Add SGLT2 inhibitor when metformin monotherapy fails to achieve A1C <7% 5
• Empagliflozin demonstrated 0.84% A1C reduction versus placebo with zero severe hypoglycemia episodes 5
• Most common side effect is genital mycotic infections (mild to moderate, easily treatable) 5
• Requires adequate renal function (eGFR ≥45 mL/min/1.73 m²) for full glucose-lowering efficacy 5

Social Determinants and Access

Cost Considerations

• Routinely assess all people with diabetes for financial obstacles that could impede diabetes management. 1
• Clinicians, diabetes care team members, and social services professionals should work collaboratively to implement cost-reduction strategies 1
• For patients with cost-related barriers, consider lower-cost medications (metformin, sulfonylureas, thiazolidinediones, human insulin) within context of hypoglycemia risk, weight gain, cardiovascular and kidney events, and other adverse effects. 1

Health Inequities

• Providers must assess social context including food insecurity, housing stability, and financial barriers, applying this information to treatment decisions. 1
• Refer patients to local community resources when available 1
• Provide self-management support from lay health coaches, navigators, or community health workers when available 1
• Up to 25% of insulin-prescribed patients report cost-related insulin underuse 1

Common Pitfalls to Avoid

• Do not delay therapy intensification when A1C goals are not met after 3 months—prolonged hyperglycemia increases complication risk. 4
• Avoid overbasalization with insulin by addressing postprandial hyperglycemia appropriately; consider adding prandial insulin at 4 units daily or 10% of basal dose, titrating by 1-2 units or 10-15% based on individualized needs. 4
• Do not use SGLT2 inhibitors as monotherapy in patients with random glucose ≥250 mg/dL or A1C ≥8.5%—these patients require insulin initially 5
• Do not discontinue SGLT2 inhibitors solely because glucose-lowering efficacy declined with reduced eGFR—cardiovascular and renal benefits persist 5
• For metformin with reduced renal function (eGFR <45 ml/min/1.73 m²), dose adjustments are necessary; consider temporarily discontinuing before iodinated contrast procedures, during hospitalizations, and when acute illness may compromise renal or liver function 4