Today, we’re comparing the American Diabetes Association's Pharmacological Approaches to Glycemic Treatment to last year’s version. This specific guideline is published annually in the ADA’s Standards of Care in Diabetes, which releases in January of each year.
Since it’s an annual publication, the ADA maintains its Standards of Care in Diabetes guideline based on the latest evidence-based insights. In doing so, each release features several detailed changes reflected throughout the guideline.
For today’s article, we are focusing on the Pharmacological Approaches to Glycemic Treatment section, marked as section 9 in the Standards of Care in Diabetes guideline. Many of the changes offer clarifying language, with some clear comparisons outlined below, followed by a more detailed overview of key changes.
Guidelines Referenced:
Standards of Care in Diabetes 2025
Standards of Care in Diabetes 2024
- January 2024
- Full Text
Comparing Pharmacological Approaches to Glycemic Treatment, Example Recommendation Changes from 2024 to 2025
| Recommendation | 2024 | 2025 |
|---|---|---|
| 9.7 | Insulin treatment plan and insuling-taking behavior shouldbe reevaluated at regular intervals (e.g., every 3–6 months( and adjusted to incorporate specific factors that imace choice of treatment and ensure achievemnt of individualied glycemic goals. | Healthy behaviors, diabetes self-management education and support, avoidance of therapeutic inertia, and social determinants of health should be included in the glucose-lowering management of T2D. |
| 9.8 | Healthy lifestyle behaviors, diabetes self-management education and support, avoidance of therapeutic inertia, and social determinants of health should be considered in the glucose-lowering management of type 2 diabetes. | A person-centered shared decision-making approach should guide the choice of glucose-lowering medications for adults with type 2 diabetes. Use medications that provide sufficient effectiveness to achieve and maintain intended treatment goals with consideration of the effects on cardiovascular, kidney, weight, and other relevant comorbidities; hypoglycemia risk; cost and access; risk for adverse reactions and tolerability; and individual preferences. |
| 9.10 | The glucose-lowering treatment plan should consider approaches that support weight management goals for adults with type 2 diabetes. | In adults with T2D and established or high risk of atherosclerotic cardiovascular disease, the treatment plan should include medications with demonstrated benefits to reduce cardiovascular events (e.g., glucagon-like peptide 1 receptor agonist and/or sodium-glucose cotransporter 2 inhibitor) for glycemic management and comprehensive cardiovascular risk reduction (irrespective of A1C). |
Major Changes and Key Takeaways From 2025's Pharmacological Approaches to Glycemic Treatment
In the 2025 release of Standards of Care in Diabetes, section 9, Pharmacological Approaches to Glycemic Treatment saw an expansion in the form of two sections: “Additional Recommendations for All Individuals with Diabetes” and “Special Circumstances and Populations” were added in. The following is an overview of those additions along with many others.
- Recommendation 9.8 received revised phrasing to better emphasize the importance of selecting glucose-lowering medications that provide sufficient effectiveness and achieve and maintain multiple treatment goals at the same time.
- Additionally, recommendations 9.10, 9.11, and 9.12 were revised to provide better advice on the choice of pharmacotherapy for individuals with T2D and an established or at high-risk of atherosclerotic cardiovascular disease (ASCVD), heart failure, and chronic kidney disease (CKD), to improve health outcomes to improve their conditions irrespective of A1C.
- Recommendation 9.12 was added to recommend the use of GLP-1 RA with demonstrated benefits in individuals with T2D, symptomatic heart failure with preserved ejection fraction, and obesity.
- Recommendation 9.13 was updated to recommend the use of either SGLT2 inhibitor or GLP-1 RA with demonstrated benefits in individuals with T2D and CKD.
- Recommendation 9.15 and 9.16 were both added to the recommend treatment of individuals with T2D and MASLD or MASH with GLP-1 RA, dual GIP and GLP-1 RA and pioglitazone based on the staging of liver disease risk and the need for weight management.
- Recommendation 9.20 was clarified to recommend reassessing the need and/or dose of medications with higher hypoglycemia risk.
- Recommendation 9.21 was created to advise against using a dipeptidyl peptidase 4 inhibitor with a GLP-1 RA due to the lack of additional glucose lowering behind that of a GLP-1 RA alone.
- Recommendation 9.24 had its phrasing adjusted to specify that a GLP-1 RA or a dual GIP and GLP-1 RA is preferred to insulin in adults with T2D only in the absence of evidence of insulin deficiency.
- Recommendation 9.27 saw a revisionment that removed consideration of basal insulin doses exceeding 0.5 units/kg/day as evidence of overbasalization. Instead, signs of overbasalization including notable bedtime-to-morning or postprandial-to-preprandial glucose differential, occurrences of hypoglycemia (aware or unaware), and high glycemic variability should be used.
- Recommendations 9.31a, 9.31b, 9.31c were added to provide advice on actions to take when medications are not available (i.e., due to medication shortages).
- Recommendations 9.32a and 9.32b were added to address care considerations for individuals of childbearing potential.
- Recommendation 9.33 was added to provide guidance on mitigating risk of ketoacidosis when individuals at risk for ketoacidosis or who follow a ketogenic eating pattern are treated with SGLT inhibition.
- Table 9.2 was adjusted to better feature considerations for choosing medications for lowering glucose in T2D.
- Tables 9.3 and 9.4 received a refresh. They were both updated with glucose-lowering medication and insulin costs that were accurate as of July 1, 2024. Additionally, an expanded section discussing medication costs and affordability was added.
- Figure 9.1 received updated wording for clarity regarding dose adjustments when using AID systems. The section on insulin administration was expanded to also include the use of insulin bolus patches and inhaled insulin.
- Figure 9.3 was revised to better facilitate evidence-based selection of glucose-lowering therapies based on personalized treatment goals. Additional considerations for glucose-lowering medication effects on MASLD and MASH were added in.
- Figure 9.4 was adjusted for clarity and the list of options for prandial insulin was enhanced.
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