What are the 2026 American Diabetes Association (ADA) clinical practice recommendations for screening, diagnosis, glycemic targets, lifestyle modification, pharmacologic therapy, cardiovascular and renal risk reduction, and monitoring in adults with diabetes?

2026 ADA Guidelines for Diabetes Management

First-Line Therapy

Metformin combined with lifestyle modifications is mandatory first-line therapy for all adults with type 2 diabetes unless contraindicated, and must be continued even when adding other agents or insulin. 1, 2

• Continue metformin when initiating insulin therapy for ongoing glycemic and metabolic benefits 1
• Monitor vitamin B12 levels during long-term metformin use, particularly if anemia or peripheral neuropathy develops 2, 3

Glycemic Targets

Target HbA1c between 7-8% for most adults with type 2 diabetes, moving away from the traditional <7% target to reduce hypoglycemia and overtreatment risks. 2, 3

• For patients on lifestyle modification alone or metformin monotherapy (no hypoglycemia risk), aim for HbA1c of 6.5% 3
• For patients on medications that cause hypoglycemia (sulfonylureas, insulin), target HbA1c of 7.0% 3
• Deintensify treatment immediately when HbA1c falls below 6.5% to avoid hypoglycemia and overtreatment 2, 3
• Relax targets in older/frail adults with limited life expectancy, high fall risk, impaired hypoglycemia awareness, or significant comorbidities 1, 3

Second-Line Therapy: Organ Protection Over Glycemic Control

Prioritize organ protection by selecting second-line agents based on the presence of heart failure, chronic kidney disease, or cardiovascular risk rather than HbA1c alone. 2

When Metformin Fails to Achieve Target:

• Add SGLT2 inhibitor if patient has heart failure, chronic kidney disease, or cardiovascular risk 2, 3
• Add GLP-1 receptor agonist if patient has increased stroke risk or needs substantial weight loss 2, 4
• For adults with BMI >25, tirzepatide provides superior glycemic control and weight loss (mean 8.47 kg, with 67% achieving ≥10% weight reduction) compared to other GLP-1 agonists 4

Critical Medication Hierarchy:

• GLP-1 receptor agonists are preferred over insulin when possible (Grade A recommendation) 1, 2
• If insulin is ultimately required, combination therapy with a GLP-1 receptor agonist is recommended for greater efficacy, durability, weight benefit, and hypoglycemia reduction 1, 2

Early Combination Therapy

• Consider early combination therapy at treatment initiation to extend time to treatment failure 1
• Early introduction of insulin should be considered if there is ongoing catabolism (weight loss), symptoms of hyperglycemia, or when A1C levels >10% or blood glucose ≥300 mg/dL 1

Discontinuation of Inferior Medications

Discontinue sulfonylureas and reduce long-acting insulins when SGLT2 inhibitors or GLP-1 agonists achieve adequate glycemic control, due to increased severe hypoglycemia risk without mortality benefit. 2, 4

• When adding insulin to sulfonylureas, immediately reduce sulfonylurea dose by 50% to prevent severe hypoglycemia 4
• Do not combine tirzepatide with DPP-4 inhibitors—provides no additional glucose lowering 4

Weight Management Integration

Weight management is now explicitly integrated into diabetes treatment algorithms, with glucose-lowering treatment plans required to support weight management goals. 1, 2

• For adults with BMI >25, weight loss medications may be effective as adjuncts to diet, physical activity, and behavioral counseling 4
• Discontinue weight loss medications if response is <5% weight loss after 3 months 4

Screening Recommendations

• Screen all asymptomatic adults ≥35 years using fasting plasma glucose, HbA1c, or 2-hour oral glucose tolerance test 3
• Screen adults <35 years if BMI ≥25 kg/m² (≥23 kg/m² for Asian Americans) plus any additional risk factor 3
• Repeat screening every 3 years if normal; annually if prediabetes identified 3, 5
• Screen children/adolescents after puberty or age ≥10 years if overweight/obese plus additional risk factors 3

Diagnostic Criteria

• HbA1c ≥6.5% (using NGSP-certified laboratory method only—not point-of-care) 3, 5
• Fasting plasma glucose ≥126 mg/dL (after ≥8-hour fast) 3, 5
• 2-hour oral glucose tolerance test ≥200 mg/dL (75g glucose load) 3, 5
• Random plasma glucose ≥200 mg/dL plus classic hyperglycemic symptoms (polyuria, polydipsia, unexplained weight loss) 3, 5
• Confirm all positive results on a separate day except random glucose ≥200 mg/dL with symptoms 3, 5

Monitoring and Reassessment

Medication regimens must be reevaluated every 3-6 months and adjusted based on glycemic control, weight goals, metabolic comorbidities, and hypoglycemia risk. 1, 2

• Do not delay treatment intensification when patients fail to meet goals—therapeutic inertia worsens long-term outcomes 1, 4
• Clinicians should be aware of overbasalization with insulin (basal dose >0.5 units/kg/day, high bedtime-morning glucose differential, hypoglycemia, high glycemic variability) 1

Cardiovascular and Renal Risk Reduction

In adults with type 2 diabetes and established or high risk of atherosclerotic cardiovascular disease, heart failure, or chronic kidney disease, the treatment plan must include agents that reduce cardiovascular and kidney disease risk, irrespective of glycemia. 1, 3

• ACE-inhibitor therapy for patients with established cardiovascular disease 3
• β-blockers for ≥2 years after myocardial infarction 3
• Aspirin 75-162 mg/day for secondary prevention; clopidogrel 75 mg/day if aspirin allergy 3
• Optimize both glycemic and blood pressure control to reduce nephropathy risk 3

Blood Pressure Management

• Measure blood pressure at every routine diabetes visit 3
• Target systolic <130 mmHg and diastolic <80 mmHg 3
• For BP 130-139/80-89 mmHg, initiate lifestyle therapy for up to 3 months; add pharmacologic agents if targets unmet 3
• For BP ≥140/90 mmHg, start pharmacologic therapy immediately plus lifestyle measures 3

Lipid Management

• Obtain fasting lipid profile at least annually 3
• Add statin therapy for all diabetic patients with overt cardiovascular disease and those >40 years with cardiovascular risk factors 3
• Primary LDL goal: <100 mg/dL; intensive goal <70 mg/dL for established cardiovascular disease 3
• If LDL targets not achieved on maximal statin, aim for 30-40% reduction from baseline 3

Lifestyle Modifications

• Prescribe ≥150 minutes per week of moderate-intensity aerobic activity spread over at least 3 days with no more than 2 consecutive days without activity 3, 4
• Add resistance training 2-3 sessions weekly on nonconsecutive days 3, 4
• Recommend Mediterranean or DASH dietary pattern emphasizing whole grains, legumes, nuts, fruits, vegetables, minimal processed foods 3
• Limit sodium to <2,300 mg/day 3
• Eliminate sugar-sweetened beverages entirely 3
• Break up prolonged sedentary periods to lower postprandial glucose 3

Special Populations: Older Adults

• Select medications with low hypoglycemia risk in older adults 1
• Overtreatment is common in older adults and should be avoided 1
• Deintensify hypoglycemia-causing medications (insulin, sulfonylureas, meglitinides) or switch to low-risk classes for high-risk individuals 1
• Simplify complex treatment plans (especially insulin) to reduce hypoglycemia risk and treatment burden 1
• Recommend healthful eating with adequate protein intake to prevent sarcopenia 1
• For older adults with type 2 diabetes, overweight/obesity, and capacity to exercise safely, intensive lifestyle intervention focused on dietary changes, physical activity, and modest weight loss (5-7%) should be considered 1

Complication Screening

• Retinopathy: Initial dilated eye exam within 5 years of type 1 diagnosis or shortly after type 2 diagnosis; annually thereafter (or every 2-3 years after consecutive normal exams); more frequently if retinopathy progressing 3
• Foot care: Annual comprehensive foot examination including visual inspection, foot pulses, and 10-g monofilament testing plus one additional modality 3
• Nephropathy: Optimize glycemic and blood pressure control 3

Immunizations

• Annual influenza vaccine for all diabetic patients ≥6 months 3
• Pneumococcal polysaccharide vaccine for all diabetic patients ≥2 years; one-time revaccination for those <64 years previously immunized before age 65 if >5 years elapsed 3
• Hepatitis B vaccination per CDC recommendations 3

Cost Considerations

Discuss medication costs with patients when selecting from SGLT2 inhibitors or GLP-1 agonists, and prescribe generics when available. 2

• Consider costs of care and coverage when developing treatment plans to reduce cost-related barriers to medication adherence 1
• In cost-constrained situations, maximize sulfonylurea dose when newer agents are unaffordable, but immediately reduce dose by 50% when adding insulin 4

Critical Pitfalls to Avoid

• Do not rely on random capillary blood glucose for screening—less standardized despite reasonable sensitivity 3
• Do not use HbA1c alone in patients with hemoglobinopathies or conditions affecting red-cell turnover—confirm with plasma glucose 3
• Do not use point-of-care HbA1c assays for diagnosis—only NGSP-certified laboratory methods acceptable 3
• Do not delay treatment intensification—recommendation for intensification should not be delayed for individuals not meeting goals 1, 4
• Avoid thiazolidinediones in patients with symptomatic heart failure 3
• Metformin may be used in stable heart failure with normal renal function but avoid in unstable/hospitalized heart failure patients 3