2025 Οι νέες οδηγίες για το διαβήτη – Αμερικανική Διαβητολογική Εταιρεία (A.D.A.)

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Table 2.3 was added to provide considerations related to the use and interpretation of laboratory measurement of glucose and A1C. The “Classification” subsection has been updated to provide a pragmatic approach to management of individuals who have features of both type 1 and type 2 diabetes. In the “Type 1 Diabetes” subsection, Recommendation 2.7 was added to emphasize the importance of antibody-based screening for presymptomatic type 1 diabetes in individuals with a family history of type 1 diabetes or otherwise known elevated genetic risk. The associated text was also updated and expanded to reflect these changes. The “Gestational Diabetes Mellitus” subsection was completely updated to facilitate understanding and implementation of the current various approaches to screening for and diagnosis of gestational diabetes mellitus (GDM). more ➥

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Language in Fig. 4.1 was updated, and Table 4.1 was modified to include changes made throughout Section 4. Recommendation 4.3 was changed to include assessment for glycemic status and previous treatment at the initial visit and follow-up visits as appropriate. Table 4.2 was amended to include essential components for assessment, planning, and referral as appropriate. Changes were made in the “Immunizations” subsection to reflect updates for COVID-19, pneumococcal pneumonia, influenza, and respiratory syncytial virus. Table 4.3 was revised to include important vaccination updates. Recommendation 4.6 was modified to specify initial and repeat screening for autoimmune thyroid disease. Recommendation 4.10 was updated to specify avoiding medications with known association with higher fracture risk. Recommendation 4.12 was revised to include the recommended intake of calcium for people with diabetes. Recommendation 4.13 was updated to specify when antiresorptive medications and osteoanabolic agents should be considered. more ➥

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Recommendation 6.12 was added to promote routine screening for fear of hypoglycemia in individuals at risk for hypoglycemia. A new subsection entitled “Hyperglycemic Crises: Diagnosis, Management, and Prevention” was added to cover the epidemiology, diagnostic criteria, and outpatient prevention of DKA and the hyperglycemic hyperosmolar state (HHS). New recommendations on routine assessment of history of DKA and HHS (recommendation 6.20) and providing structured prevention education (Recommendation 6.21) in the outpatient setting were added. Tables 6.9 and 6.10 were added and include risk factors for hyperglycemic crises as well as clinical presentation of DKA and HHS in people with diabetes, respectively. Figure 6.2 was revised to provide a specific and actionable approach to selecting individual glycemic goals, accounting for health status and other person- and treatment-specific factors favoring more or less stringent goals.

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Recommendation 8.2a was updated to clarify that additional measurements of body fat distribution are warranted if BMI is indeterminant. Recommendation 8.2b was revised to recommend monitoring of obesity-related anthropometric measurements at least every 3 months during active weight management treatment. Discussion of weight stigma and bias toward people living in larger bodies was added to the text. Recommendation 8.11 was enhanced to reflect the importance of continued monitoring, support, and interventions for individuals who have achieved weight loss goals to support the maintenance of these goals long term. Recommendation 8.18 was added to recommend screening for malnutrition for people with diabetes and obesity who have lost significant weight. Recommendation 8.19 was added to recommend continuing weight management pharmacotherapy, as indicated, beyond reaching weight loss goals to maintain health benefits and avoid weight regain and worsening of cardiometabolic abnormalities that often result from sudden discontinuation of weight management pharmacotherapy. more ➥

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This section was reorganized and expanded with two new subsections: 1) a subsection titled “Additional Recommendations for All Individuals With Diabetes” that includes new recommendations as well as recommendations previously listed with those for individuals with type 1 or type 2 diabetes if pertinent to individuals regardless of their type of diabetes, and 2) a subsection titled “Special Circumstances and Populations.” Figure 9.1 was revised for clarity, and a general statement was added to Table 9.1 on dose adjustments when using AID systems. The subsection on insulin administration technique was expanded to address inhaled insulin and use of insulin bolus patches. Recommendation 9.8 was revised to emphasize the importance of selecting glucose-lowering medications that provide sufficient effectiveness and achieve and maintain multiple treatment goals simultaneously, including improving cardiovascular, kidney, weight, and other relevant outcomes, reducing hypoglycemia risk, and considering cost, access, risk for adverse reactions, and individual preferences. more ➥

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Recommendation 10.1 was updated with details on the frequency of recommended blood pressure monitoring. Figure 10.2 was updated to provide clarity on medication classes for the treatment of confirmed hypertension in nonpregnant people with diabetes. Recommendation 10.12 was modified to specify appropriate monitoring for increased serum creatinine levels, serum potassium levels, and hypokalemia when ACE inhibitors, angiotensin receptor blockers (ARBs), or mineralocorticoid receptor antagonists are used. Recommendation 10.13 was added to specify hypertension treatment options that should be avoided during pregnancy and in sexually active individuals of childbearing potential not using reliable contraception. Recommendation 10.26 was added to recommend that in most cases lipid-lowering agents should be discontinued prior to conception and avoided in sexually active individuals of childbearing potential not using reliable contraception, unless the benefits may outweigh the risk. Figures 10.3 and 10.4 were added to illustrate recommendations for primary prevention and secondary prevention of ASCVD, respectively, in people with diabetes using cholesterol-lowering therapy. Triglyceride thresholds were updated in Recommendations 10.31 and 10.32. more ➥

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Recommendation 11.3 was amended for clarity about optimizing blood pressure management goals. Recommendation 11.4a was revised to clarify that ACE inhibitors or ARBs should be titrated to the maximally tolerated dose to prevent the progression of CKD and reduce cardiovascular events in nonpregnant individuals with diabetes and hypertension. Recommendation 11.4b was modified to specify appropriate monitoring for increased serum creatinine levels, serum potassium levels, and hypokalemia when ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists are used. Recommendation 11.5b was updated to state that for people with type 2 diabetes and CKD, a GLP-1 RA with demonstrated benefit in this population should be used to reduce cardiovascular risk and kidney disease progression. Recommendation 11.6 was added to state that potentially harmful antihypertensive medications in pregnancy should be avoided in sexually active individuals of childbearing potential not using reliable contraception and to switch to options considered safer prior to conception and during pregnancy. Recommendation 11.7 was updated to specify reducing urinary albumin by ≥30% to slow progression of CKD. Recommendation 11.8 was updated to specify protein goals for individuals with stage 3 or higher CKD and those who are treated with dialysis. Table 11.1 was added to include reasons to consider non–diabetes-related kidney diseases in a person with CKD and diabetes, and Table 11.3 was added to include suggestions for interventions that lower albuminuria. more ➥

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Recommendation 12.5 was updated to specify involvement of an ophthalmologist for more frequent examinations if retinopathy is progressing or sight threatening. Recommendation 12.8 wording was changed to reflect that a dilated eye exam should be performed before and in the first trimester, rather than one or the other. Recommendation 12.19 was modified to include additional screening criteria for symptoms and signs of autonomic neuropathy. Recommendation 12.22 was updated to recommend against opioid use for neuropathic pain treatment due to the potential for adverse events, and the narrative text was updated to expand on this. A short discussion on the role of weight management and neuropathy was added to the narrative text. Recommendation 12.24 was updated to include the Ipswich touch test as an option for neurological assessment. more ➥

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The 4Ms framework of age-friendly health systems (Mentation, Medications, Mobility, and What Matters Most) as it applies to diabetes management in older adults was introduced and illustrated in the new Fig. 13.1. Recommendation 13.8a was modified to include time in range and time below range in addition to A1C treatment goals for older adults who are otherwise healthy with few and stable chronic conditions and intact cognitive functional status. Recommendation 13.8b was modified to include time in range and time below range in addition to A1C treatment goals for older adults who have intermediate or complex health who are clinically heterogeneous with variable life expectancy. more ➥

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Recommendation 14.4 in the “Type 1 Diabetes” section was added to emphasize key nutrition principles. Recommendation 14.10 was altered to emphasize limits on sedentary activity. Recommendation 14.21 was changed to state that insulin pumps should be offered to anyone with type 1 diabetes who can use the devices safely. Recommendation 14.24 was modified to remove lack of access as a reason for less stringent A1C goals. Recommendation 14.26 was altered to include weight gain as a balancing measure for more stringent A1C goals. Recommendation 14.36 was changed to exclude secondary causes of hypertension. Recommendation 14.41 was updated to include the use of age-approved statins. Recommendation 14.50 was modified to state that screening should be repeated at a minimum of 2-year intervals or more frequently if screening is normal and BMI is increasing. Recommendation 14.57 was revised to include the key nutritional principles and provide specific examples of healthy food choices and what foods should be avoided. more ➥

Section 15. Management of Diabetes in Pregnancy

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Section 15 was restructured to discuss the care of pregnant individuals with type 1 diabetes, type 2 diabetes, and GDM in all sections and to discuss aspects of management in each relevant subsection (e.g., preconception care and pharmacotherapy); consequently, the order of appearance of some of the recommendations changed. Recommendation 15.7 wording was changed to reflect that a dilated eye exam should be performed before and in the first trimester, rather than one or the other. Table 15.1 was updated with a folic acid supplement recommendation of 400–800 μg/day and clarification for which checklist items are only for individuals with preexisting diabetes and not for individuals with prediabetes or a history of GDM, and specific immunizations were omitted and referenced. In Recommendation 15.10, the benefits of CGM use in type 1 diabetes and pregnancy were clarified, and an addition of its potential to be beneficial in other types of diabetes in pregnancy was added. more ➥

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Diabetes care in the hospital stresses identification and treatment of dysglycemia and provides glycemic goals. For the treatment of persistent hyperglycemia starting at a threshold of ≥180 mg/dL (≥10.0 mmol/L), Recommendation 16.4a was amended to reflect that insulin should be initiated or intensified for the majority of critically ill individuals, and Recommendation 16.4b was added to state that insulin and/or other glucose-lowering therapies should be initiated or intensified for the majority of noncritically ill individuals. Recommendation 16.5a was updated to state that a glycemic goal of 140–180 mg/dL (7.8–10.0 mmol/L) is recommended for most critically ill individuals, but more stringent individualized glycemic goals may be appropriate if they can be achieved without significant hypoglycemia. Recommendation 16.5b was updated to recommend a glycemic goal of 100–180 mg/dL (5.6–10.0 mmol/L) for most noncritically ill individuals if it can be achieved without significant hypoglycemia. more ➥

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