Standards of Care in Diabetes-2025

Introduction

The American Diabetes Association (ADA) released the Standards of Care (SoC) in Diabetes-2025 on 9th December 2024 and it marks a significant transfor-mative step in diabetes management. This SoC has been considered as the definitive resource for evidence-based guidelines to make diagnosis, treatment, and prevention of diabetes across all age groups belonging to diverse populations. The ADA’s annual guidelines have provided methods to prevent or delay the onset of type 2 diabetes and its associated co-morbidities and to improve outcomes for individuals affected by diabetes or at risk of developing the condition.¹ By integrating the latest advancements in research, therapeutics, and technology, the ADA provides a comprehensive roadmap to enhance patient outcomes and address the global burden of diabetes.

ADA updates its SoC annually through its think tank, the Professional Practice Committee (PPC), comprising leading global experts from different professional backgrounds who reflect the latest advancements in research, technology, and therapeutics.

There are continuous changes in the care of diabetes that are occurring constantly to facilitate improvement in the health and well-being of individuals having diabetes. These annual updates have been made since 45 years (1989).

Many of these changes suggested in different sections have received endorsement from prestigious organizations such as the American Society for Bone and Mineral Research, the Obesity Society, the American College of Cardiology, and the American Geriatric Society. The guidelines have emphasized the importance of personalized care with detailed recommendations for special populations and challenging clinical scenarios. They have been discussed in 17 sections. The key highlights have been summarised as follows:

Comprehensive Framework for Diabetes Manage-ment

1. Improvement of Care and Promotion of Population Health

The section advocates a holistic approach to care, addressing not only individuals with diabetes but also those at risk for diabetes. It has analyzed the health outcomes after implementing improved diabetes care methods that include a Patient-centered Medical Home model. It has stressed the value of screening for and addressing different social determinants of health having an impact on the management of diabetes, in turn improving quality of life through targeted interventions. It has stressed undertaking person-centered care of individuals with diabetes in various age groups.

2. Diagnosis and Classification of Diabetes

The section has stressed the integration of glucose estimation and A1C metrics for diagnostic precision. Further it has stressed the importance of antibody-based screening for pre-symptomatic type 1 diabetes in persons having a family history of type 1 diabetes or otherwise known increased genetic risk. It has revised the methodology of diagnosis of gestational diabetes mellitus (GDM). The section has considered the potential roles of immune inhibitors, and the gut microbiome in influencing diabetes risk. This has paved the way for innovative therapeutic approaches. The oral and injectable therapy for the management of diabetes has been tailored to individual patient needs.

3. Prevention or Delay of Type 2 Diabetes and Co-morbidities

This section has discussed the changes in lifestyle behavior for Type 2 diabetes. It has considered the importance of sleep health as a lifestyle behavior in the management of prediabetes. Considering the pharmacologic interventions to delay Type 2 Diabetes, it has highlighted the importance of Vitamin D therapy in reducing diabetes risk. It has drawn attention to the need for monitoring vitamin B12 levels in individuals on long-term metformin therapy.

4. Comprehensive Evaluation and Assessment of Co-morbidities

This section has stressed the importance of regular assessment of glycemic status and previous treatment at the initial and subsequent visits. Further, it has highlighted the importance of regular vaccination against pneumococcal pneumonia, influenza, and respiratory syncytial virus. It is necessary to undertake screening for autoimmune thyroid disease. It has stressed the need to avoid medications that have higher fracture risk and to take calcium preparations regularly. Bone mineral density should be measured regularly. Individuals with diabetes should undergo dental checkups annually. The presence of any disability should not be missed. In males, the estimation of the level of testosterone may be necessary if there is the presence of hypogonadism. Men must be screened for erectile dysfunction. Similarly, sexual dysfunction in women must be enquired and it is especially necessary for women with diabetes exhibiting depression, anxiety, and recurrent urinary tract infections. The presence of liver disease should be evaluated. People with diabetes should follow a structured nutrition plan and physical activity program. They are deemed essential for managing associated conditions effectively.

5. Positive Health Behaviors

The section has stressed the need to follow positive health behaviors to improve health outcomes. Empowering patients through self-management education is pivotal. People with diabetes should be well-versed with self-management. Individuals who are obese or overweight should be advised properly about the importance of nutrition, dietary supplements, limitation in consumption of processed foods, limitation of sodium intake, and adequate intake of water instead of sweetened beverages. They should be encouraged to use plant-based proteins and fiber, physical activity, and inculcation of positive healthy behavior. These individuals should be screened periodically for mental health issues such as diabetes, distress, depression, anxiety, fear of hypoglycemia, and disordered eating behaviors. They are necessary to foster resilience and adherence.

6. Glycaemic Goals and Crisis Management

The prevention and management of hyperglycaemic crises, including diabetic ketoacidosis (DKA) and hyperosmolar hyperglycaemic states (HHS), are discussed in detail, with an emphasis on routine monitoring and early intervention.

7. Diabetes Technology

Technological innovations continue to transform diabetes care. Continuous glucose monitoring (CGM) systems, connected insulin delivery devices, continuous subcutaneous insulin infusion and automated insulin delivery systems, and automated insulin pumps should be standardized to ensure consistent and effective usage. These devices are revolutionizing diabetes care. Patients should be trained to maximise the benefits of these technologies. It should be noted that many medications and other substances, and medical conditions, may influence glucose levels and lead to cardiometabolic abnormalities.

8. Obesity and Weight Management

Given the inextricable link between obesity and type 2 diabetes, the guidelines advocate for sustained weight management strategies to prevent cardiometabolic complications. Patients achieving weight loss are encouraged to adopt long-term maintenance plans to avoid regaining weight.

9. Pharmacological Approaches to Glycaemic Treat-ment

The section on pharmacological interventions has been significantly expanded, providing detailed guidance on glucose-lowering medications and insulin administration techniques. Recent advancements in combination therapies are also discussed, aiming to achieve and maintain multiple treatment goals.

Oral Glucose-Lowering Medications

The 2025 guidelines provide expanded guidance on oral therapies tailored to individual patient profiles. Key updates include:

• Metformin: Recommended as first-line therapy for type-2 diabetes, with long-term use necessitating monitoring of vitamin B12 levels.

• SGLT2 Inhibitors: Demonstrated efficacy in improving glycaemic control while offering cardiovascular and renal protective effects. It is particularly beneficial for patients with heart failure or chronic kidney disease (CKD).

• DPP-4 Inhibitors: Effective in moderate glycaemic control with minimal risk of hypoglycaemia, making them suitable for elderly patients.

• Sulfonylureas: While cost-effective, these agents require caution due to their association with hypoglycaemia and weight gain.

• Thiazolidinediones (TZDs): Recommended for specific patient groups but necessitate careful monitoring for fluid retention and cardiovascular risk.

Injectable Therapies: Insulin and GLP-1 Receptor Agonists

• Basal Insulin: Preferred for initiating insulin therapy, with long-acting analogues minimizing nocturnal hypoglycemia.

• Bolus Insulin: Tailored to postprandial glucose levels with flexible dosing strategies.

• GLP-1 Receptor Agonists: Dual benefits of glycemic control and weight reduction. The guidelines underscore their utility in combination therapy, particularly for patients with obesity or cardiovascular risks.

10. Cardiovascular Disease and Risk Management

The guidelines have stressed the importance of regular blood pressure monitoring and the careful management of cardiovascular risk factors, including peripheral artery disease and symptomatic and undiagnosed heart diseases. Blood pressure control targeting <130/80 mmHg in most patients with ACE inhibitors or ARBs as the first line of therapy has been stressed. Creatinine and potassium levels should be routinely assessed in hypertensive patients undergoing treatment. Lipid management with statins for patients at high cardiovascular risk, supplemented by ezetimibe or PCSK9 inhibitors in refractory cases is advised.

11. Chronic Kidney Disease (CKD) and Risk Management

It is essential to achieve optimum blood pressure goals in patients with CKD. There is a need to titrate the dose of ACE inhibitors or ARBs to prevent the progression of CKD. Diabetes in patients with CKD require the administration of SGLT2 inhibitors that have proven to slow CKD progression and reduce albuminuria. The dose of metformin and insulin has to be carefully titrated based on renal function.

12. Retinopathy, Neuropathy, and Foot Care

Regular screening for diabetic retinopathy, and auto-nomic neuropathy, coupled with preventive measures for lower extremity complications, must be undertaken. Opioids to treat neuropathic pain have to be avoided. Smoking must be stopped to prevent lower extremity complications. It has recommended structured foot care programs to reduce the risk of amputation.

13. Diabetes in Older Adults

The elderly population is increasing all over the world. The problems faced by them are dealt with in this section. Management of diabetes in the elderly must be undertaken in the framework of 4Ms (Mentation, Medication, Mobility and What Matters Most). Individualised A1C targets (e.g. <8%) are less stringent for frail individuals to avoid hypoglycaemia. There is a need to avoid agents with high hypoglycaemic risk such as sulphonylureas. There should be effective and safe management for this vulnerable population.

14. Diabetes in Children and Adolescents

The guidelines have stressed the importance of achieving AIC goal of <6.5%. It has emphasized adopting healthy eating habits, and avoiding sedentary activity. The nomenclature of ‘hyperglycemic hyperosmolar nonketotic syndrome’ has been changed to ‘hyperglycemic hyperosmolar state’ giving clarity to the condition.

15. Diabetes in Pregnancy

A unified approach to managing gestational and pre-existing diabetes during pregnancy has been adopted. Recommendations include folic acid supplementation of 400-800 mg/day to prevent neural tube defects. The terms such as management of GDM, management of pre-existing type 1 diabetes, and type 2 diabetes in pregnancy have been merged into one as management of diabetes in pregnancy. It includes all aspects of the management of different types of diabetes. Metformin and glyburide should not be first-line therapy in them. Insulin is the preferred therapy due to its safety profile. Glycaemic targets to be achieved are fasting glucose <5.3 mmol/L and postprandial levels <6.7 mmol/L. Lipid-lowering agents are to be avoided during pregnancy.

16. Diabetes Care in Hospital Settings

The section stresses the need for the identification and treatment of dysglycemia and has offered glycemic goals to be achieved during hospitalization. Timely interventions can significantly improve patient outcomes in these settings. Insulin therapy is preferred for managing hyperglycaemia with intravenous insulin for critically ill patients. Glycaemic targets have to be achieved by maintaining glucose levels between 7.8- 10 mmol/L to minimise complications. The transition of care has to be ensured by seamless post-discharge management to prevent readmission.

17. Diabetes Advocacy

The final section highlights the importance of advocacy, particularly in the school setting and driving safety, to ensure equitable and supportive environments for individuals with diabetes.

Emerging Therapies

The guidelines have acknowledged novel approaches, including:

• Combination Therapies: Exploiting synergistic effects of GLP-1 receptor agonists and SGLT2 inhibitors.

• Precision Medicine: Tailoring interventions based on genetic, metabolic, and behavioral phenotypes.

• Vitamin D Supplementation: Its potential role in reducing diabetes risk and progression is under investigation.

Conclusion

The ADA Standards of Care in Diabetes-2025 has provided a meticulously crafted roadmap for diabetes management, to clinicians, researchers, and policymakers. It has integrated the latest research, technology, and innovative therapies, with an aim to revolutionise diabetes care globally and improve the lives of millions of individuals. By focussing on both established and emerging therapies and the nuanced needs of special populations, these guidelines have offered a comprehensive approach to address this global health challenge. The increasing prevalence of diabetes has made it necessary to adhere to these recommendations which are critical in improving patient outcomes and shaping the future of diabetes care. ADA is bringing out the guidelines annually to improve the lives of persons affected by diabetes. Thus, it gives support to persons with diabetes and to the persons who help in the management of diabetes.

Conflict of interest

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Financial support

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