Diabetes Care Volume 47, Supplement 1, January 2024 S5

Summary of Revisions: Standards American Diabetes Association

Professional Practice Committee*
of Care in Diabetes—2024
Diabetes Care 2024;47(Suppl. 1):S5–S10 | https://doi.org/10.2337/dc24-SREV

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GENERAL CHANGES health outcomes, costs, individual prefer- hierarchy to acknowledge real-world prac-
The field of diabetes care is rapidly chang- ences and goals, and treatment burden. tice when diagnosing diabetes and predia-
ing as new research, technology, and treat- The subsection “Status and Demo- betes, respectively.
ments that can improve the health and graphics of Diabetes Care,” formerly “Care Recommendation 2.5 was added to
well-being of people with diabetes con- Delivery Systems,” was updated to include emphasize the importance of differenti-

SUMMARY OF REVISIONS
tinue to emerge. With annual updates current data with respect to cholesterol, ating which form of diabetes an individ-
since 1989, the American Diabetes Associ- blood pressure, and glycemic management. ual has in order to facilitate personalized
ation (ADA) has long been a leader in pro- The “Cost Considerations for Medication- management.
ducing guidelines that capture the most Taking Behaviors” subsection now includes Figure 2.1 was added as a new figure
current state of the field. costs of insulin and glucose monitoring to provide a structured framework for in-
The 2024 Standards of Care includes devices, with an update on insulin price vestigation of suspected type 1 diabetes
revisions to incorporate person-first and lowering. in newly diagnosed adults.
inclusive language. Efforts were made to Language was added to the “Home- The “Type 1 Diabetes” subsection was
consistently apply terminology that em- lessness and Housing Insecurity” subsec- updated to refine diagnostic criteria for
powers people with diabetes and rec- tion to reflect issues more accurately in type 1 diabetes based on recent U.S. Food
ognizes the individual at the center of this population. and Drug Administration (FDA) approval
diabetes care. The “Social Capital and Community of a new drug to delay the incidence of
Although levels of evidence for sev- Support” subsection now discusses the type 1 diabetes. Recommendations 2.6
eral recommendations have been up- possible role of community paramedics and 2.7, for type 1 diabetes, were up-
dated, these changes are not outlined in community-based diabetes care. dated accordingly.
below where the clinical recommenda- Recommendation 2.8 was added for
tion has remained the same. That is, Section 2. Diagnosis and consideration of standardized islet auto-
changes in evidence level from, for ex- Classification of Diabetes antibody tests for classification of diabe-
ample, E to C are not noted below. The (https://doi.org/10.2337/dc24-S002) tes in adults who phenotypically overlap
2024 Standards of Care contains, in ad- The title of Section 2 was changed to with type 1 diabetes, and a new para-
dition to many minor changes that clarify “Diagnosis and Classification of Diabetes” to graph was added to highlight the possible
recommendations or reflect new evidence, better represent real-world clinical practice association between coronavirus disease
more substantive revisions detailed (i.e., diagnosis occurs before classification). 2019 (COVID-19) infection and new-onset
below. Recommendation 2.1a was added to type 1 diabetes.
emphasize the structured approach to di- Recommendation 2.15a was added to
SECTION CHANGES agnostic testing, and Recommendation emphasize the role of several medication
Section 1. Improving Care and 2.1b was updated to highlight the impor- classes in increasing the risk of prediabe-
Promoting Health in Populations tance of confirmatory testing when an ab- tes and type 2 diabetes and the need for
(https://doi.org/10.2337/dc24-S001) normal test result is identified. screening.
Recommendation 1.4 was updated to em- Tables 2.1 and 2.2 were modified to Recommendation 2.15b was added to
phasize improving processes of care and include A1C at the top of the testing provide screening guidance for prediabetes

*A complete list of members of the American Diabetes Association Professional Practice Committee can be found at https://doi.org/10.2337/dc24-SINT.
Duality of interest information for each author is available at https://doi.org/10.2337/dc24-SDIS.
Suggested citation: American Diabetes Association Professional Practice Committee. Summary of revisions: Standards of Care in Diabetes—2024. Diabetes
Care 2024;47(Suppl. 1):S5–S10
© 2023 by the American Diabetes Association. Readers may use this article as long as the work is properly cited, the use is educational and not
for profit, and the work is not altered. More information is available at https://www.diabetesjournals.org/journals/pages/license.
S6 Summary of Revisions Diabetes Care Volume 47, Supplement 1, January 2024

and type 2 diabetes in individuals treated with The subsection on "Bone Health" has of addressing barriers to using DSMES
second-generation antipsychotic medications. been extensively revised and updated services.
In the “Pancreatic Diabetes or Diabetes in to reflect the current best practices in Recommendation 5.13 was added to
the Context of Disease of the Exocrine the field. Recommendations 4.9–4.14 the “Medical Nutrition Therapy” subsec-
Pancreas” subsection, Recommendation were added to include regular evalua- tion to incorporate inclusive food-based
2.17 was added to highlight the impor- tion and treatment for bone health, and eating patterns with key nutrition princi-
tance of screening for diabetes in people accompanying text was expanded to re- ples that are foundational to all people
following an episode of acute pancreatitis flect these updates. Table 4.5 was added with diabetes, and Recommendation 5.20
or in individuals with chronic pancreatitis. to include general and diabetes-specific was updated to emphasize including
In addition, the discussion on cystic risk factors for fracture. healthy fats within the context of a Med-
fibrosis–related diabetes (CFRD) was in- Recommendation 4.22 was added to iterranean style of eating.
corporated into this subsection. Recom- include assessment and referral to appro- A subsection on religious fasting was
mendation 2.19 was modified to clarify priate health care professionals who spe- added, and the concept of chrononutrition

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that while A1C is not recommended as a cialize in disability management, which (impact of eating on circadian rhythms)
screening test for CFRD due to low sensi- was expanded upon in the text. was introduced.
tivity, it is widely used in clinical practice, Major changes regarding liver dis- Recommendation 5.23 was updated
and a value of $6.5% ($48 mmol/mol) is ease in people with diabetes were pre- to include advising alcohol abstainers to
consistent with a diagnosis of CFRD. viously added as a 2023 Living Standards not begin use of alcohol for the purpose
update, with extensive recommendations of improving health outcomes.
Section 3. Prevention or Delay of for screening and management to be in The text on nonnutritive sweeteners
Diabetes and Associated alignment with other professional socie- was expanded to address the World Health
Comorbidities ties. In addition, the recently proposed Organization’s conditional recommendation
(https://doi.org/10.2337/dc24-S003) changes in the nomenclature proposed on their use and safety.
Recommendation 3.2 was added to state for steatotic liver disease is discussed. The In the “Physical Activity” subsection,
the importance of monitoring individuals terminology for nonalcoholic fatty liver dis- Recommendation 5.31 was updated to
at risk for developing type 1 diabetes, as ease and nonalcoholic steatohepatitis was define sedentary behavior and to be in-
a younger age of seroconversion (partic- maintained at this time. clusive of all types of diabetes. The text of
ularly under age 3 years), the number of The “Bone Health” subsection is en- this subsection was updated to include a
diabetes-related autoantibodies identi- dorsed by the American Society for Bone discussion of the application and benefits
fied, and the development of autoanti- and Mineral Research. of high-intensity interval training.
bodies against islet antigen 2 (IA-2) have The subsection “Smoking Cessation:
all been associated with more rapid pro- Section 5. Facilitating Positive Health Tobacco, E-cigarettes, and Cannabis” was
gression to clinical type 1 diabetes. Behaviors and Well-being to Improve
updated to include cannabis. Although
Recommendation 3.15 was added to Health Outcomes
not enough data are available to support
address use of teplizumab, which was (https://doi.org/10.2337/dc24-S005)
a new recommendation, the text of this
approved to delay the onset of stage 3 The recommendations and text of Sec-
tion 5 were adjusted to place focus on subsection was revised to include a dis-
type 1 diabetes in adults and pediatric
guiding the behavior of health care pro- cussion on cannabis use. In addition, Rec-
individuals (aged 8 years and older) with
fessionals rather than people with dia- ommendation 5.33 was updated to advise
stage 2 type 1 diabetes.
betes, thus aligning with the purpose of that clinicians ask people with diabetes
the Standards of Care as guidance for about use of cigarettes or other tobacco
Section 4. Comprehensive Medical
Evaluation and Assessment of health care professionals. products and make appropriate referrals
Comorbidities Recommendation 5.2 was updated to for cessation as a routine component of
(https://doi.org/10.2337/dc24-S004) reflect five critical times to evaluate the diabetes care and education.
In Recommendation 4.1, language was need for diabetes self-management and Recommendation 5.36 in the “Psycho-
modified to be more inclusive for com- education (DSMES): at diagnosis, when social Care” subsection was updated to
prehensive medical evaluation. not meeting treatment goals, annually, provide greater detail for psychosocial
Figure 4.1 was updated to include in- when complicating factors develop, and screening protocols, including diabetes-
dividual lifestyle choices when choosing when transitions in life and care occur. related mood concerns, stress, and quality
treatment, and Table 4.1 was modified to Recommendation 5.4 was updated of life.
include changes made throughout Section 4. to include a broader integration of cul- Recommendation 5.39 was changed to
Changes were made in the “Immuni- tural sensitivity in the context of person- specify the frequency for diabetes distress
zations” subsection to reflect the COVID-19 centered care. screening and to highlight the role of
post-pandemic period, and updates were Recommendation 5.5 reflects inclusion health care professionals in addressing dia-
made regarding the respiratory syncytial of telehealth and digital interventions for betes distress. The accompanying text also
virus vaccine in adults $60 years of age DSMES. includes links to validated measures of dia-
with chronic conditions such as diabetes. The “Diabetes Self-Management Edu- betes distress.
Table 4.4, formerly Table 4.5, was re- cation and Support” subsection text was Recommendation 5.40 has been up-
vised to include these important vaccina- updated to reflect changes in DSMES re- dated to include screening for fear of
tion updates. imbursement policies and the importance hypoglycemia.
diabetesjournals.org/care Summary of Revisions S7

Recommendation 5.41 has been up- to highlight the benefits of continuous glu- cleared for integration with AID systems
dated to reflect increased frequency for cose monitoring (CGM) use for hypoglyce- and to include the benefits of CGM use in
depression screening and monitoring in mia prevention. Recommendation 6.12 was type 2 diabetes for those using noninten-
people with a history of depression. revised to provide hypoglycemia treatment sive insulin therapy and/or not using insulin
In the “Sleep Health” subsection, Rec- guidance inclusive of individuals using auto- therapy. In addition, the text was updated
ommendation 5.51 was added to recom- mated insulin delivery (AID) systems, and to include suggestions to streamline the
mend practicing sleep-promoting routines details were added to the text. Recommen- approach to CGM interpretation by various
and habits. dation 6.13 was revised to clarify criteria for methods, such as assessing data sufficiency
prescribing glucagon and express preference and reviewing glycemic trends to modify
Section 6. Glycemic Goals and for glucagon preparations that do not have therapeutic approaches.
Hypoglycemia to be reconstituted. Table 6.6 was added to The text on real-time CGM was up-
(https://doi.org/10.2337/dc24-S006) summarize currently available glucagon dated to outline the systems that can be
The title of Section 6 was changed to products and their monthly costs. Recom- used by pregnant individuals with diabe-

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“Glycemic Goals and Hypoglycemia,” and mendation 6.14 was added to address the tes, and substances that interfere with
hypoglycemia content throughout the need for patient education for hypoglyce- CGM device accuracy were updated in the
Standards of Care was consolidated into mia prevention and treatment, especially text and in Table 7.4.
this section. for insulin users. Recommendations 6.15 Recommendation 7.24 was refined to
Recommendation 6.1 was updated to and 6.16 were updated to communicate emphasize the usefulness of insulin pens
include more frequent glycemic assess- how hypoglycemic events should inform or insulin injection aids for people with
ment for populations needing closer gly- modification of the diabetes treatment dexterity issues or vision impairment.
cemic monitoring. The text on AID systems was updated
plan and to direct clinicians to use evi-
The “Glycemic Assessment by A1C” to include benefits reported from real-
dence-based interventions to reestablish
subsection was revised to reflect recent world studies.
awareness of hypoglycemia, respectively.
data on the strengths and limitations of the Recommendation 7.33 was added to
Table 6.7 was added to summarize
A1C assay and to include a discussion of emphasize continuation of personal CGM
the components of hypoglycemia preven-
the benefits and limitations of serum gly- use in hospitalized individuals with diabetes
tion and their recommended frequency.
cated protein assays as alternatives to A1C. when clinically appropriate in a hybrid fash-
Table 6.2 was updated to outline CGM ion and under an institutional protocol.
Section 7. Diabetes Technology
metrics and recommended glycemic goals.
(https://doi.org/10.2337/dc24-S007)
The subsections “Glucose Lowering and Section 8. Obesity and Weight
Recommendation 7.1 was added to state
Microvascular Complications” and “Glucose Management for the Prevention and
that people with diabetes should be of-
Lowering and Cardiovascular Disease Treatment of Type 2 Diabetes
fered any type of diabetes device (e.g., in- (https://doi.org/10.2337/dc24-S008)
Outcomes” were updated to include evi-
dence on long-term follow-up of clinical sulin pens, connected pens, glucose Language throughout the section was
trials of tight glycemic management and meters, and CGM or AID systems), and amended to be person centered and to
to put these findings into the context of Recommendation 7.2 was added to em- emphasize the importance of weight man-
newer diabetes medications with cardio- phasize the need to start CGM early in agement within the overall context of the
vascular and renal benefits. type 1 diabetes, even at diagnosis, to pro- treatment of people with diabetes, and
Recommendations 6.8a and 6.8b were mote early achievement of glycemic goals. the justification for a weight-based ap-
added to clarify the clinical scenarios Recommendation 7.3 was added to proach to diabetes treatment has been ex-
where deintensifying diabetes medications emphasize that health care professionals panded. The recommendations and text
is appropriate, and text in the “Setting should acquire sufficient knowledge for pertaining to weight management treat-
and Modifying Glycemic Goals” subsec- the use and application of diabetes tech- ment have been expanded to acknowl-
tion was added to discuss the rationale nology for people with diabetes, and the edge the expected range of benefits
for this update. text has been expanded to discuss the across the spectrum of weight loss.
Recommendations 6.11a, 6.11b, and need for both knowledge and compe- Recommendations 8.2a, 8.2b, and 8.3
6.11c were added to clarify when and tency for interprofessional teams manag- were expanded to incorporate additional
how health care professionals should re- ing diabetes care. anthropometric measurements beyond BMI
view an individual’s hypoglycemia history, Recommendation 7.8 was modified (i.e., waist circumference, waist-to-hip ratio,
awareness, and risk. Table 6.5, which pro- to align with Section 14, “Children and and/or waist-to-height ratio) to encourage
vides a summary of hypoglycemia risk Adolescents,” to support initiation of an individualized assessments of body fat mass
factors (formerly in Section 4), was up- insulin pump and/or AID system early for and distribution.
dated to reflect recent evidence. The individuals with type 1 diabetes, even at Recommendation 8.6 was added to
“Hypoglycemia Risk Assessment” sub- diagnosis. highlight that approaches to treating obe-
section was added to provide the back- Recommendation 7.15 was updated to re- sity should be individualized and that any of
ground and rationale for Table 6.5. flect the benefits of intermittently scanned the established approaches (i.e., intensive
Several recommendations were added to CGM in less intensively treated people with behavioral interventions, pharmacologic
and updated within the “Hypoglycemia As- type 2 diabetes. treatment, or metabolic surgery) can be
sessment, Prevention, and Treatment” sub- The text on CGM systems was expanded considered in people with obesity and dia-
section. Recommendation 6.11d was added to include updates on systems that are betes alone or in combination.
S8 Summary of Revisions Diabetes Care Volume 47, Supplement 1, January 2024

Recommendation 8.8b was updated 9.4 was added to indicate consideration for considered at any stage irrespective of
to suggest counseling strategies to ad- use of AID systems for adults with type 1 other glucose-lowering medications in
dress barriers to access. diabetes. certain circumstances.
Recommendations 8.11a and 8.11b Recommendation 9.5 was expanded Recommendation 9.23 was updated
were updated to highlight the effective- to include educating adults with type 1 to include a dual GIP and GLP-1 receptor
ness of weight maintenance programs diabetes on how to modify their insulin agonist as an additional option for greater
and to suggest monitoring weight loss dose based on concurrent glycemia, gly- glycemic management that is preferred
progress while providing ongoing sup- cemic trends, and sick day management. to insulin, and Recommendation 9.24 was
port for maintaining goals long term. Recommendation 9.6 was added to updated to reflect reassessing insulin dos-
Recommendation 8.17 was added to suggest prescribing glucagon for indi- ing upon addition or dose escalation of a
include glucagon-like peptide 1 (GLP-1) re- viduals taking insulin or at high risk for GLP-1 receptor agonist or a dual GIP and
ceptor agonists or a dual glucose-dependent hypoglycemia. GLP-1 receptor agonist.
insulinotropic polypeptide (GIP) and GLP-1 Recommendation 9.7 was added to Recommendation 9.25 was broadened

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receptor agonist with greater weight loss emphasize the importance of regular to include any glucose-lowering agents
efficacy as preferred pharmacotherapy treatment plan evaluation for individu- if justified for additional benefits (e.g.,
for obesity management in people with als with diabetes to ensure individual- weight management, cardiometabolic,
diabetes. ized goals are met. or kidney benefits) to treatment goals.
Recommendation 8.18 was added to Recommendation 9.14 was updated Recommendation 9.26 was added to
address the importance of reevaluation to highlight the importance of early suggest reassessing the need and/or dos-
for obesity treatment intensification or combination therapy when shortening ages for other glucose-lowering agents
deintensification for people with diabe- the time to attainment of individualized that are associated with higher risk of hy-
tes to reach their weight goals. treatment goals for adults with type 2 poglycemia when initiating or intensifying
The text of the “Metabolic Surgery” diabetes. insulin treatment.
subsection was updated to emphasize Recommendation 9.15 was added to Recommendations 9.28 and 9.29 were
preventing and addressing therapeutic reflect that pharmacologic therapies should added to provide guiding principles of
inertia pertaining to weight manage- address both individualized glycemic and care for people with obstacles that may
ment goals in people with obesity and weight goals in adults with type 2 diabetes impede their diabetes management.
type 2 diabetes. without cardiovascular and/or kidney Figure 9.1 was updated to reflect a
Recommendation 8.19 was updated disease. terminology change from “hybrid closed-
in response to growing evidence of the Recommendation 9.16 was added to loop technology” to “automated insulin
long-term benefits of metabolic surgery advise consideration of additional glucose- delivery systems.”
treatment in people with obesity and lowering agents for adults with type 2 dia- Table 9.1 was updated to reflect ter-
type 2 diabetes. betes not meeting their individualized gly- minology updates, and Table 9.2 was up-
Recommendation 8.20 now includes cemic goals. dated to include counseling people with
a link to accredited metabolic and bar- Recommendation 9.17 was added to diabetes about potential for ileus (subcu-
iatric surgery centers. highlight the importance of treatment taneous semaglutide) and to include that
Recommendation 8.25 was added to intensification and combination of ap- dual GIP and GLP-1 receptor agonist treat-
emphasize the importance of monitor- proaches pertaining to weight manage- ment is not recommended for individuals
ing weight loss progress of individuals ment and their alignment with glycemic with a history of gastroparesis.
who have undergone metabolic surgery. management goals for adults with type 2 Tables 9.3 and 9.4 were updated to
In the case of inadequate progress, po- diabetes. reflect changes in cost for several agents.
tential barriers and additional weight Recommendation 9.18 was updated to
loss interventions should be considered. reflect prioritizing glycemic management Section 10. Cardiovascular Disease
Table 8.1 was updated to include the agents that also reduce cardiovascular and and Risk Management
recent FDA approvals and price changes kidney disease risk in adults with type 2 (https://doi.org/10.2337/dc24-S010)
for several obesity pharmacotherapies. diabetes and established/high risk of ath- Recommendation 10.12 was revised to
This section is endorsed by The Obe- erosclerotic cardiovascular disease, heart recommend monitoring of serum creati-
sity Society. failure, and/or chronic kidney disease. nine/estimated glomerular filtration rate
For adults with type 2 diabetes who and potassium within 7–14 days after ini-
Section 9. Pharmacologic have heart failure, Recommendation tiation of treatment with an ACE inhibitor,
Approaches to Glycemic Treatment 9.19 was added to recommend sodium– angiotensin receptor blocker, mineralocor-
(https://doi.org/10.2337/dc24-S009) glucose cotransporter 2 (SGLT2) inhibi- ticoid receptor agonist, or diuretic.
Recommendation 9.2 was updated to tors for glycemic management and pre- Recommendation 10.24 was added to
reflect preference of insulin analogs or vention of heart failure hospitalizations. include bempedoic acid treatment for
inhaled insulin over injectable human Recommendations 9.20 and 9.21 were people with diabetes and without estab-
insulins to minimize hypoglycemia risk added to reflect individualized recommen- lished cardiovascular disease who are in-
for most adults with type 1 diabetes. dations for individuals with type 2 diabe- tolerant to statin therapy. In addition,
Recommendation 9.3 was added to tes and chronic kidney disease. Recommendation 10.28b recommends
include early use of CGM for adults with Recommendation 9.22 was updated bempedoic acid or proprotein conver-
type 1 diabetes, and Recommendation to reflect that insulin therapy should be tase subtilisin/kexin type 9 (PCSK9)
diabetesjournals.org/care Summary of Revisions S9

inhibitor therapy with monoclonal anti- confirmed hypertension in nonpregnant to include the importance of an inter-
body treatment or inclisiran siRNA as al- people with diabetes. professional approach facilitated by a
ternative cholesterol-lowering therapy. This section is endorsed by the Amer- podiatrist with other appropriate team
A new subsection, “Intolerance to Statin ican College of Cardiology. members for individuals who have foot
Therapy,” was added to expand on these ulcers and high-risk feet (e.g., individu-
updates. Section 11. Chronic Kidney Disease als on dialysis, with Charcot foot, with
Recommendation 10.35b has been and Risk Management prior ulcer or amputation history, or
modified to recommend an interprofes- (https://doi.org/10.2337/dc24-S011) with peripheral artery disease).
sional team approach that includes a Section 11 was updated to align with Table 12.2 was updated to include
cardiovascular or neurological specialist the latest consensus report on diabetes “Fish skin graft” under “Acellular matrix
to decide on the length of treatment management in chronic kidney disease tissues” for advanced wound therapies.
with dual antiplatelet therapy in peo- by the ADA and Kidney Disease: Improv-
ple with diabetes after an acute coronary ing Global Outcomes (KDIGO). Section 13. Older Adults

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syndrome or ischemic stroke/transient is- Recommendation 11.4a was updated (https://doi.org/10.2337/dc24-S013)
chemic attack. to include the role of ACE inhibitors or an- Recommendation 13.6 was modified to
Recommendations 10.39a and 10.39b giotensin receptor blockers in preventing align with the revised Medicare reim-
were added to include screening of adults the progression of kidney disease and re- bursement rules allowing CGM for adults
with diabetes for asymptomatic heart fail- ducing cardiovascular events. with type 2 diabetes on any insulin.
ure by measuring a natriuretic peptide Recommendation 11.7 was updated Recommendations 13.8a, 13.8b, and
level to facilitate the prevention or pro- to reflect dietary protein intake levels for 13.8c were amended to highlight the het-
gression to symptomatic stages of heart individuals with stage 3 or higher chronic erogeneity present for treatment goals
failure. kidney disease who are currently treated for older adults, especially those with in-
Recommendation 10.40 was modified with dialysis. termediate or complex health conditions
to include screening for peripheral artery Figure 11.1 was updated and illustrates who need to personalize glycemic goals.
chronic kidney disease progression, fre- Recommendations 13.16a–13.16d were
disease with ankle-brachial index testing
quency of visits, and referral to nephrol-
in asymptomatic people with diabetes updated to highlight the need to dein-
ogy according to glomerular filtration rate
aged $50 years , microvascular disease in tensify therapy, most particularly hypo-
and albuminuria. Figure 11.2 was added
any location, foot complications, or any glycemia-causing medications (such as
to present a holistic approach for improv-
end-organ damage from diabetes. Periph- insulin, sulfonylureas, and meglitinides).
ing outcomes in individuals with diabetes
eral artery disease screening should be These recommendations also suggest
and chronic kidney disease.
considered for individuals with diabetes switching to classes of glucose-lowering
for $10 years or more. medications with a lower risk of hypo-
Section 12. Retinopathy, Neuropathy,
Recommendation 10.42a was updated glycemia to meet individualized glycemic
and Foot Care
to recommend either an SGLT2 inhibitor (https://doi.org/10.2337/dc24-S012) goals. In addition, treatment plans for
or an SGLT1/2 inhibitor for people with di- Language in Recommendations 12.1, 12.2, older adults with diabetes and other co-
abetes and established heart failure with 12.5, and 12.7 was refined to be more ac- morbidities (e.g., atherosclerotic cardio-
preserved or reduced ejection fraction to tionable by health care professionals. vascular disease, heart failure, and/or
reduce risk of worsening heart failure and Recommendation 12.6 was updated to chronic kidney disease) should include
cardiovascular death. Additional text in- indicate the application of FDA-approved agents that reduce cardiorenal risk, re-
cludes a discussion on cardiovascular out- artificial intelligence algorithms, and the gardless of glycemia.
comes trials of the SGLT1/2 inhibitor text was updated with approved artificial
sotagliflozin. intelligence algorithm details and clinical Section 14. Children and Adolescents
Recommendations 10.45a–10.45e have trials. (https://doi.org/10.2337/dc24-S014)
been added to address treatment ap- Recommendations 12.15 and 12.16 were Recommendation 14.4 was added to state
proaches for people with diabetes and added to address vision loss from diabetes, the need for insulin dosing adjustments
heart failure, including the roles of an in- and the text was expanded to discuss com- according to meal composition.
terprofessional team and pharmacological plications of vision loss and the importance In the “Psychosocial Care” subsection,
approaches to prevent heart failure pro- of evaluation and rehabilitation. Recommendation 14.10 was revised to
gression and hospitalization. The text in the “Neuropathy” subsec- include screening details for psychosocial
Recommendation 10.47 was added to tion was updated to discuss the limited and behavioral health concerns and for
suggest including education on risks and data available to support use of lidocaine appropriate referral when indicated, and
signs of ketoacidosis and methods of man- 5% plaster/patch and gastric stimulation Recommendation 14.12 was updated to
agement and tools for testing in people as efficacious therapies for people with clarify diabetes distress and lower en-
with type 1 diabetes, ketosis-prone type 2 diabetes. gagement in diabetes self-management
diabetes, and/or those consuming keto- In the "Foot Care" subsection, Rec- behavior.
genic diets treated with SGLT inhibition. ommendation 12.27 was updated to in- Recommendation 14.53 was modified
Figure 10.2 was modified to reflect clude toe pressures when screening for to state “at least” a 7–10% decrease in
changes in initial blood pressure values peripheral artery disease. In addition, excess weight for youth with overweight
and treatment recommendations for Recommendation 12.28 was amended and obesity with type 2 diabetes when
S10 Summary of Revisions Diabetes Care Volume 47, Supplement 1, January 2024

recommending developmentally and endocrinology health care professional, institutions to perform regular audits to
culturally appropriate comprehensive life- and Recommendation 15.5 was expanded monitor proper use of protocols and to
style programs. to include physical activity for preconception ensure institute educational/training pro-
Recommendations 14.68 and 14.70 care. grams keep staff up to date.
were updated to include consideration In the “Glycemic Goals in Pregnancy” Recommendation 16.4 was updated
for empagliflozin prior to initiating and/or subsection, Recommendation 15.7 was to reflect that insulin and other therapies
intensifying insulin therapy plans for glyce- modified to emphasize that all pregnant should be initiated or intensified for treat-
mic management, and Fig. 14.1 was up- individuals with diabetes should monitor ment of persistent hyperglycemia starting
dated to include empagliflozin. fasting, preprandial, and postprandial blood at a threshold of 180 mg/dL (10.0 mmol/L).
Recommendation 14.69 was added glucose levels, and Recommendation 15.10 Recommendation 16.5a was added to
to suggest consideration for medication- was updated to include CGM use for preg- delineate the glycemic goals for most
taking behavior and the medications’ nant individuals with type 1 diabetes. critically ill individuals with hyperglycemia
effects on weight for youth with over- The text in “Insulin Physiology” was (target glucose range of 140–180 mg/dL

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weight or obesity and type 2 diabetes. expanded to include information about [7.8–10.0 mmol/L]), and Recommen-
The term “severe obesity” in Recom- changes to basal and bolus insulin re- dation 16.5b was updated to suggest
mendation 14.72 was changed to “class 2 quirements as pregnancy progresses for more stringent goals (110–140 mg/dL
obesity or higher (BMI >35 kg/m2 or individuals with preexisting diabetes. [6.1–7.8 mmol/L]) for selected critically ill
120% of 95th percentile for age and sex, The text in “Glucose Monitoring” was individuals if these goals can be achieved
whichever is lower)” to provide greater updated to differentiate lower limits of without significant hypoglycemia.
details for adolescents being considered glucose thresholds based on blood and Recommendations 16.6 and 16.7 were
for metabolic surgery. sensor glucose monitoring. added to indicate continued use of
Recommendation 14.78 was updated Language was added to “Continuous personal CGM devices and use of AID sys-
to clarify protein intake according to age Glucose Monitoring in Pregnancy” to en- tems in conjunction with CGM, respec-
for those with nephropathy. courage individualization for CGM use in tively, in the inpatient setting if clinically
The new subsection “Substance Use in pregnant individuals with type 2 diabetes
appropriate, with confirmatory point-
Pediatric Diabetes” includes Recommen- of-care glucose measurements for insulin
or gestational diabetes mellitus (GDM).
dations 14.106 and 14.107 to discourage dosing decisions and hypoglycemia assess-
Language was also added to clarify the
initiation of smoking (tobacco and elec- ment, if resources and training are avail-
international consensus on time in range
tronic cigarettes) and to encourage smok- able, and according to an institutional
for pregnant individuals with type 2 dia-
ing cessation. The text was expanded protocol. The narrative has also been
betes or GDM.
to discuss the adverse health effects of expanded to recommend a personal-
Recommendation 15.15 was updated
smoking and exposure to secondhand ized approach for achieving glycemic
to clarify that metformin and glyburide,
smoke for youth with diabetes. goals throughout the hospital stay.
individually or in combination, should
In the “Transition from Pediatric to In the “Perioperative Care” subsec-
not be used as first-line agents for treat- tion, a statement was added about the
Adult Care” subsection, Recommenda-
ing hyperglycemia in pregnancy. safe use of GLP-1 receptor agonists in
tions 14.108 and 14.109 were revised
Language was added to the “Pre- the perioperative period.
to reflect the role of interprofessional
teams in the transition from pediatric eclampsia and Aspirin” subsection to The “Glucose-Lowering Treatment in
to adult care and to be more person note that individuals with GDM may also Hospitalized Patients” subsection dis-
centered. Recommendation 14.110 was be candidates for aspirin therapy if they cusses the evidence on the coadministra-
added to give direction for the coordi- have a single high risk factor or multiple tion of a low dose of basal insulin analog
nation between pediatric diabetes spe- moderate risk factors. while on intravenous insulin infusion.
cialists and youth with diabetes and Recommendation 15.27 was updated to For the management of diabetic ketoa-
their caregivers on the timing of trans- encourage breastfeeding efforts for all indi- cidosis and hyperglycemic hyperosmolar
fer to adult care. viduals with diabetes who are postpartum. state, the text has been expanded to include
The “Postpartum Care” subsection was a nurse-driven protocol with a variable rate
Section 15. Management of Diabetes updated to explain that a preconception based on glucose values as an option.
in Pregnancy evaluation is needed for individuals with Recommendation 16.11 was added to
(https://doi.org/10.2337/dc24-S015) childbearing potential who have predia- indicate the use of SGLT2 inhibitors for in-
“Reproductive potential” was changed to betes or a history of GDM. dividuals with type 2 diabetes hospitalized
“childbearing potential” throughout the with heart failure during hospitalization
section to be more specific. “Women” Section 16. Diabetes Care in the Hospital and that SGLT2 inhibitors should be con-
was changed to “individuals” throughout (https://doi.org/10.2337/dc24-S016) tinued after recovery from acute illness if
the section, except for instances men- Recommendation 16.2 was expanded to no contraindications are present.
tioning the title of a published study, to emphasize the need for personalized ap-
be more inclusive. proaches in the emergency department, Section 17. Diabetes Advocacy
In the “Preconception Care” subsection, intensive care unit and nonintensive care (https://doi.org/10.2337/dc24-S017)
Recommendation 15.4 was updated to unit wards, gynecology-obstetrics/delivery The Care of Young Children With Diabetes
highlight the approach of interprofessional units, dialysis suites, and psychiatric wards. in the Childcare and Community Setting
care and the need for inclusion of an The text has been expanded to encourage advocacy statement has been updated.