Diabets Ada

STANDARDS OF CARE
Standards of Medical Care in Diabetes—2021 Abridged

for Primary Care Providers
American Diabetes Association
The American Diabetes Association (ADA) Standards of Thus, efforts to improve population health will require a
Medical Care in Diabetes is updated and published annually combination of policy-level, system-level, and patient-
in a supplement to the January issue of Diabetes Care. The level approaches. Patient-centered care is defined as care
Standards are developed by the ADA’s multidisciplinary that considers individual patient comorbidities and
prognoses; is respectful of and responsive to patient
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Professional Practice Committee, which comprises physi-
cians, diabetes educators, and other expert diabetes health preferences, needs, and values; and ensures that patient
care professionals. The Standards include the most current values guide all clinical decisions. Further, social deter-
evidence-based recommendations for diagnosing and minants of health (SDOH)—often out of direct control of
treating adults and children with all forms of diabetes. the individual and potentially representing lifelong
ADA’s grading system uses A, B, C, or E to show the evidence risk—contribute to medical and psychosocial outcomes
level that supports each recommendation. and must be addressed to improve all health outcomes.
• A—Clear evidence from well-conducted, generalizable
randomized controlled trials that are adequately Recommendations
powered
1.2 Align approaches to diabetes management with the
• B—Supportive evidence from well-conducted cohort
Chronic Care Model (CCM). This model emphasizes
studies
person-centered team care, integrated long-term
• C—Supportive evidence from poorly controlled or
treatment approaches to diabetes and comorbidities,
uncontrolled studies
and ongoing collaborative communication and goal
• E—Expert consensus or clinical experience
setting between all team members. A
This is an abridged version of the current Standards 1.3 Care systems should facilitate team-based care
containing the evidence-based recommendations most and utilization of patient registries, decision support
pertinent to primary care. The recommendations tables tools, and community involvement to meet patient
and figures included here retain the same numbering used needs. B
in the full Standards and so are not numbered sequen- 1.4 Assess diabetes health care maintenance (see Table 4.1
tially. All of the recommendations included here are in the complete 2021 Standards of Care) using
substantively the same as in the full Standards. The reliable and relevant data metrics to improve
abridged version does not include references. The processes of care and health outcomes, with attention
complete 2021 Standards of Care, including all sup- to care costs. B
porting references, is available at professional.
diabetes.org/standards. Six Core Elements
The CCM includes six core elements to optimize the care
1. IMPROVING CARE AND PROMOTING HEALTH of patients with chronic disease:
IN POPULATIONS 1. Delivery system design (moving from a reactive to a
proactive care delivery system where planned visits are
Diabetes and Population Health coordinated through a team-based approach)
Clinical practice recommendations can improve health 2. Self-management support
across populations; however, for optimal outcomes, di- 3. Decision support (basing care on evidence-based,
abetes care must also be individualized for each patient. effective care guidelines)
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14 CLINICAL.DIABETESJOURNALS.ORG
AMERICAN DIABETES ASSOCIATION
4. Clinical information systems (using registries that can 2. CLASSIFICATION AND DIAGNOSIS OF DIABETES
provide patient-specific and population-based support
Classification
to the care team)
5. Community resources and policies (identifying or Diabetes can be classified into the following general
developing resources to support healthy lifestyles) categories:
6. Health systems (to create a quality-oriented 1. Type 1 diabetes (due to autoimmune b-cell destruction,
culture) usually leading to absolute insulin deficiency, including
latent autoimmune diabetes of adulthood)
Strategies for System-Level Improvement 2. Type 2 diabetes (due to a progressive loss of b-cell
insulin secretion frequently on the background of in-
Care Teams sulin resistance)
Collaborative, multidisciplinary teams are best suited to 3. Specific types of diabetes due to other causes, e.g.,

provide care for people with chronic conditions such as monogenic diabetes syndromes (such as neonatal di-
diabetes and to facilitate patients’ self-management. The abetes and maturity-onset diabetes of the young),
care team should avoid therapeutic inertia and prioritize diseases of the exocrine pancreas (such as cystic fibrosis
timely and appropriate intensification of lifestyle and/or and pancreatitis), and drug- or chemical-induced di-
pharmacologic therapy for patients who have not abetes (such as with glucocorticoid use, in the treat-
achieved the recommended metabolic targets. ment of HIV/AIDS, or after organ transplantation)
4. Gestational diabetes mellitus (GDM; diabetes diag-
Telemedicine nosed in the second or third trimester of pregnancy that
was not clearly overt diabetes prior to gestation)
Telemedicine is a growing field that may increase access to
care for patients with diabetes. Increasingly, evidence It is important for providers to realize that classification of
suggests that various telemedicine modalities may be diabetes type is not always straightforward at presen-
effective at reducing A1C in patients with type 2 diabetes tation, and misdiagnosis may occur. Children with type 1
compared with usual care or in addition to usual care. diabetes typically present with polyuria/polydipsia, and
approximately one-third present with diabetic ketoaci-
Behaviors and Well-Being dosis (DKA). Adults with type 1 diabetes may not present
Successful diabetes care also requires a systematic ap- with classic symptoms and may have a temporary re-
proach to supporting patients’ behavior-change efforts, mission from the need for insulin. The diagnosis may
including high-quality diabetes self-management edu- become more obvious over time and should be reeval-
cation and support (DSMES). uated if there is concern.
Tailoring Treatment for Social Context Screening and Diagnostic Tests for Prediabetes
Recommendations and Type 2 Diabetes
1.5 Assess food insecurity, housing insecurity/ The diagnostic criteria for diabetes and prediabetes are
homelessness, financial barriers, and social capital/ shown in Table 2.2/2.5. Screening criteria are listed in
social community support and apply that information Table 2.3.
to treatment decisions. A
1.6 Refer patients to local community resources when Recommendations
available. B 2.6 Screening for prediabetes and type 2 diabetes
1.7 Provide patients with self-management support from with an informal assessment of risk factors or
lay health coaches, navigators, or community health validated tools should be considered in asymptomatic
workers when available. A adults. B
Health inequities related to diabetes and its complications 2.7 Testing for prediabetes and/or type 2 diabetes in
are well documented and have been associated with asymptomatic people should be considered in
greater risk for diabetes, higher population prevalence, adults of any age with overweight (BMI 25–29.9 kg/m2
and poorer diabetes outcomes. SDOH are defined as the or 23–27.4 kg/m2 in Asian Americans) or obesity
economic, environmental, political, and social conditions (BMI $30 kg/m2 or $27.5 kg/m2 in Asian Americans)
in which people live and are responsible for a major part of and who have one or more additional risk factors
health inequality worldwide. for diabetes (Table 2.3). B
VOLUME 39, NUMBER 1, WINTER 2021 15

ABRIDGED STANDARDS OF CARE 2021
2.8 Testing for prediabetes and/or type 2 diabetes should An assessment tool such as the ADA risk test (diabetes.org/
be considered in women with overweight or obesity socrisktest) is recommended to guide providers on
planning pregnancy and/or who have one or whether performing a diagnostic test for prediabetes
more additional risk factors for diabetes or previously undiagnosed type 2 diabetes is appropriate.
(Table 2.3). C
2.9 For all people, testing should begin at age 45 years. B Marked discrepancies between measured A1C and
2.10 If tests are normal, repeat testing carried out at a plasma glucose levels should prompt consideration
minimum of 3-year intervals is reasonable, sooner that the A1C assay may not be reliable for that individual,
with symptoms. C and one should consider using an A1C assay without
2.13 Risk-based screening for prediabetes and/or type 2 interference or plasma blood glucose criteria for
diabetes should be considered after the onset of diagnosis. (An updated list of A1C assays with
puberty or after 10 years of age, whichever occurs interferences is available at ngsp.org/interf.asp.)

earlier, in children and adolescents with overweight Unless there is a clear clinical diagnosis based on
(BMI $85th percentile) or obesity (BMI $95th overt signs of hyperglycemia, diagnosis requires
percentile) and who have additional risk factors two abnormal test results from the same sample or
for diabetes. (See Table 2.4 for evidence grading in two separate test samples. If using two separate
of risk factors.) B test samples, it is recommended that the second
TABLE 2.2/2.5 Criteria for the Screening and Diagnosis of Prediabetes and Diabetes
Prediabetes Diabetes
A1C 5.7–6.4% (39–47 mmol/mol)* $6.5% (48 mmol/mol)†
Fasting plasma glucose 100–125 mg/dL (5.6–6.9 mmol/L)* $126 mg/dL (7.0 mmol/L)†
2-hour plasma glucose during 75-g OGTT 140–199 mg/dL (7.8–11.0 mmol/L)* $200 mg/dL (11.1 mmol/L)†
Random plasma glucose — $200 mg/dL (11.1 mmol/L)‡
Adapted from Tables 2.2 and 2.5 in the complete 2021 Standards of Care. *For all three tests, risk is continuous, extending below the lower limit of the
range and becoming disproportionately greater at the higher end of the range. †In the absence of unequivocal hyperglycemia, diagnosis requires two
abnormal test results from the same sample or in two separate samples ‡Only diagnostic in a patient with classic symptoms of hyperglycemia or
hyperglycemic crisis. OGTT, oral glucose tolerance test.
TABLE 2.3 Criteria for Testing for Diabetes or Prediabetes in Asymptomatic Adults
1. Testing should be considered in adults with overweight or obesity (BMI $25 kg/m2 or $23 kg/m2 in Asian Americans) who have one or more of the
following risk factors:
• First-degree relative with diabetes
• High-risk race/ethnicity (e.g., African American, Latino, Native American, Asian American, Pacific Islander)
• History of CVD
• Hypertension ($140/90 mmHg or on therapy for hypertension)
• HDL cholesterol level ,35 mg/dL (0.90 mmol/L) and/or a triglyceride level .250 mg/dL (2.82 mmol/L)
• Women with polycystic ovary syndrome
• Physical inactivity
• Other clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosis nigricans)
2. Patients with prediabetes (A1C $5.7% [39 mmol/mol], impaired glucose tolerance, or impaired fasting glucose) should be tested yearly.
3. Women who were diagnosed with GDM should have lifelong testing at least every 3 years.
4. For all other patients, testing should begin at age 45 years.
5. If results are normal, testing should be repeated at a minimum of 3-year intervals, with consideration of more frequent testing depending on initial results
and risk status.
6. HIV
test, which may either be a repeat of the initial test or Delivery and Dissemination of Lifestyle Behavior
a different test, be performed without delay. If the Change for Diabetes Prevention
patient has a test result near the margins of the The DPP research trial demonstrated that an intensive
diagnostic threshold, the provider should follow lifestyle intervention could reduce the risk of incident type 2
the patient closely and repeat the test in 3–6 diabetes by 58% over 3 years. The Centers for Disease
months. Control and Prevention (CDC) developed the National
Diabetes Prevention Program (National DPP), a resource
Certain medications, such as glucocorticoids, thiazide
designed to bring such evidence-based lifestyle change
diuretics, some HIV medications, and atypical antipsy-
programs for preventing type 2 diabetes to communities
chotics, are known to increase the risk of diabetes
(cdc.gov/diabetes/prevention).
and should be considered when deciding whether
to screen.
The Centers for Medicare & Medicaid Services has ex-

panded Medicare reimbursement coverage for the National
DPP lifestyle intervention to organizations recognized by
3. PREVENTION OR DELAY OF TYPE 2 DIABETES the CDC that become Medicare suppliers for this service.
Recommendation The locations of Medicare DPPs are available online
at innovation.cms.gov/innovation-models/medicare-
3.1 At least annual monitoring for the development of
diabetes-prevention-program/mdpp-map.
type 2 diabetes in those with prediabetes is sug-
gested. E To qualify for Medicare coverage, patients must have
a BMI in the overweight range and laboratory
testing consistent with prediabetes in the last
Lifestyle Behavior Change for Diabetes
year. Medicaid coverage of the DPP lifestyle
Prevention
intervention is also expanding on a state-by-
Recommendations state basis.
3.2 Refer patients with prediabetes to an intensive
lifestyle behavior change program modeled on Pharmacologic Interventions
the Diabetes Prevention Program (DPP) to Recommendation
achieve and maintain 7% loss of initial body weight
and increase moderate-intensity physical activity 3.6 Metformin therapy for prevention of type 2 diabetes
(such as brisk walking) to at least 150 minutes/ should be considered in those with prediabetes,
week. A especially for those with BMI $35 kg/m2, those
3.3 A variety of eating patterns can be considered aged ,60 years, and women with prior GDM. A
to prevent diabetes in individuals with prediabe- Metformin has the strongest evidence base and demon-
tes. B strated long-term safety as a pharmacologic therapy for
3.4 Based on patient preference, certified technology- diabetes prevention. Other medications have been
assisted diabetes prevention programs may be ef- studied; no pharmacologic agent has been approved by
fective in preventing type 2 diabetes and should be the U.S. Food and Drug Administration (FDA) specifically
considered. B for diabetes prevention.
TABLE 2.4 Risk-Based Screening for Type 2 Diabetes or Prediabetes in Asymptomatic Children and Adolescents in a
Clinical Setting
Testing should be considered in youth* who have overweight ($85th percentile) or obesity ($95th percentile) A and who have one or more additional risk
factors based on the strength of their association with diabetes:
• Maternal history of diabetes or GDM during the child’s gestation A
• Family history of type 2 diabetes in first- or second-degree relative A
• Race/ethnicity (Native American, African American, Latino, Asian American, Pacific Islander) A
• Signs of insulin resistance or conditions associated with insulin resistance (acanthosis nigricans, hypertension, dyslipidemia, polycystic ovary syndrome, or
small-for-gestational-age birth weight) B
*After the onset of puberty or after 10 years of age, whichever occurs earlier. If tests are normal, repeat testing at a minimum of 3-year intervals
(or more frequently if BMI is increasing or risk factor profile deteriorating) is recommended. Reports of type 2 diabetes before age 10 years exist,
and this can be considered with numerous risk factors.

Prevention of Vascular Disease and Mortality Recommendations

Recommendation 4.1 A patient-centered communication style that uses
person-centered and strength-based language and
3.8 Prediabetes is associated with heightened cardio-
active listening; elicits patient preferences and be-
vascular (CV) risk; therefore, screening for and
liefs; and assesses literacy, numeracy, and potential
treatment of modifiable risk factors for cardiovascular
barriers to care should be used to optimize patient
disease (CVD) are suggested. B
health outcomes and health-related quality of life. B
4.2 People with diabetes can benefit from a coordinated
4. COMPREHENSIVE MEDICAL EVALUATION AND multidisciplinary team that may draw from certified
ASSESSMENT OF COMORBIDITIES diabetes care and education specialists (CDCES), pri-
mary care providers, subspecialty providers, nurses,
Patient-Centered Collaborative Care
dietitians, exercise specialists, pharmacists, dentists,

A successful medical evaluation depends on beneficial in- podiatrists, and mental health professionals. E
teractions between the patient and a coordinated interdis-
The use of empowering language can help to inform and
ciplinary team. Individuals with diabetes must assume an
motivate people, yet language that shames and judges
active role in their care. The patient, family or support people,
may undermine this effort.
physicians, and health care team should together formulate
• Use language that is neutral, nonjudgmental, and based
the management plan, which includes lifestyle management.
on facts, actions, or physiology/biology.
The goals of treatment for diabetes are to prevent or • Use language free from stigma.
delay complications and optimize quality of life • Use language that is strength based, respectful, and
(Figure 4.1). Treatment goals and plans should be created inclusive and that imparts hope.
with patients based on their individual preferences, • Use language that fosters collaboration between pa-
values, and goals. tients and providers.
FIGURE 4.1 Decision cycle for patient-centered glycemic management in type 2 diabetes. HbA1c, glycated hemoglobin. Reprinted from
Davies MJ, D’Alessio DA, Fradkin J, et al. Diabetes Care 2018;41:2669–2701.
• Use language that is person centered (e.g., “person with screenings and to reduce their modifiable cancer risk
diabetes” is preferred over “diabetic”). factors (obesity, physical inactivity, and smoking).
5. FACILITATING BEHAVIOR CHANGE AND

Comprehensive Medical Evaluation WELL-BEING TO IMPROVE HEALTH OUTCOMES
Recommendations Effective behavior management and psychological
4.3 A complete medical evaluation should be performed well-being are foundational to achieving treatment
at the initial visit to: goals for people with diabetes. Essential to
• Confirm the diagnosis and classify diabetes. A achieving these goals are DSMES, medical nutrition
• Evaluate for diabetes complications and potential therapy (MNT), routine physical activity, smoking
comorbid conditions. A cessation counseling when needed, and psychosocial
• Review previous treatment and risk factor control in care.

patients with established diabetes. A
• Begin patient engagement in the formulation of a DSMES
care management plan. A
Recommendations
• Develop a plan for continuing care. A
4.4 A follow-up visit should include most components of 5.1 In accordance with the national standards for DSMES,
the initial comprehensive medical evaluation. (See all people with diabetes should participate in diabetes
Table 4.1 in the complete 2021 Standards of Care.) A self-management education and receive the
4.5 Ongoing management should be guided by the as- support needed to facilitate the knowledge, decision-
sessment of overall health status, diabetes compli- making, and skills mastery necessary for diabetes
cations, CV risk (see “The Risk Calculator” in “10. self-care. A
CVD AND RISK MANAGEMENT”), hypoglycemia 5.2 There are four critical times to evaluate the need for
risk, and shared decision-making to set therapeutic diabetes self-management education to promote skills
goals. B acquisition in support of regimen implementation,
MNT, and well-being: at diagnosis, annually and/or
Immunizations when not meeting treatment targets, when compli-
cating factors develop (medical, physical, psychoso-
The importance of routine vaccinations for people living
cial), and when transitions in life and care occur. E
with diabetes has been elevated by the coronavirus
5.3 Clinical outcomes, health status, and well-being
disease 2019 (COVID-19) pandemic. Preventing avoid-
are key goals of DSMES that should be measured as
able infections not only directly prevents morbidity but
part of routine care. C
also reduces hospitalizations, which may additionally
5.4 DSMES should be patient centered, may be given
reduce risk of acquiring infections such as COVID-19.
in group or individual settings and/or use technology,
Children and adults with diabetes should receive vacci-
and should be communicated with the entire
nations according to age-appropriate recommendations.
diabetes care team. A
5.5 Because DSMES can improve outcomes and reduce
Assessment of Comorbidities
costs B, reimbursement by third-party payers is
Cognitive Impairment/Dementia recommended. C
See “12. OLDER ADULTS.” 5.7 Some barriers to DSMES access may be mitigated
through telemedicine approaches. B
Nonalcoholic Fatty Liver Disease Evidence suggests people with diabetes who completed
Recommendation more than 10 hours of DSMES over the course of 6–12
4.10 Patients with type 2 diabetes or prediabetes and months and those who participated on an ongoing basis
elevated liver enzymes (ALT) or fatty liver on had significant reductions in mortality and A1C (decrease
ultrasound should be evaluated for presence of 0.57%) compared with those who spent less time with a
of nonalcoholic steatohepatitis and liver fibrosis. C CDCES.
DSMES is associated with an increased use of primary care
Cancer and preventive services and less frequent use of acute care
Patients with diabetes should be encouraged to undergo and inpatient hospital services. Patients who participate in
recommended age- and sex-appropriate cancer DSMES are more likely to follow best practice

treatment recommendations, particularly among the intensity or interval training may be sufficient for
Medicare population, and have lower Medicare and in- younger and more physically fit individuals.
surance claim costs. 5.28 Adults with type 1 C and type 2 B diabetes should
engage in 2–3 sessions/week of resistance exercise
MNT on nonconsecutive days.
5.29 All adults, and particularly those with type 2 dia-
All providers should refer people with diabetes for in- betes, should decrease the amount of time spent in
dividualized MNT provided by a registered dietitian daily sedentary behavior. B Prolonged sitting should
nutritionist (RD/RDN) who is knowledgeable and skilled be interrupted every 30 minutes for blood glucose
in providing diabetes-specific MNT at diagnosis and as benefits. C
needed throughout the life span, similar to DSMES. MNT 5.30 Flexibility training and balance training are rec-
delivered by an RD/RDN is associated with A1C absolute ommended 2–3 times/week for older adults with

decreases of 1.0–1.9% for people with type 1 diabetes and diabetes. Yoga and tai chi may be included based on
0.3–2.0% for people with type 2 diabetes. individual preferences to increase flexibility, mus-
cular strength, and balance. C
Eating Patterns and Meal Planning 5.31 Evaluate baseline physical activity and sedentary
time. Promote increase in nonsedentary activities above
Evidence suggests that there is not an ideal percentage of
baseline for sedentary individuals with type 1 B and
calories from carbohydrate, protein, and fat for people
type 2 E diabetes. Examples include walking, yoga,
with diabetes. Therefore, macronutrient distribution
housework, gardening, swimming, and dancing.
should be based on an individualized assessment of
current eating patterns, personal preferences (e.g.,
Exercise in the Presence of Microvascular
tradition, culture, religion, health beliefs and goals,
Complications
and economics), and metabolic goals.
Retinopathy
Weight Management If proliferative diabetic retinopathy or severe non-
proliferative diabetic retinopathy is present, then
Lifestyle intervention programs should be intensive and
vigorous-intensity aerobic or resistance exercise may be
have frequent follow-up to achieve significant reductions
contraindicated because of the risk of triggering vitreous
in excess body weight and improve clinical indicators.
hemorrhage or retinal detachment. Consultation with an
For many individuals with overweight and obesity with type ophthalmologist prior to engaging in an intense exercise
2 diabetes, 5% weight loss is needed to achieve beneficial regimen may be appropriate.
outcomes in glycemic control, lipids, and blood pressure.
The clinical benefits of weight loss are progressive, and more Peripheral Neuropathy
intensive weight-loss goals (i.e., 15%) may be appropriate to Decreased pain sensation and a higher pain threshold in
maximize benefit depending on need, feasibility, and safety. the extremities can result in an increased risk of skin
breakdown, infection, and Charcot joint destruction with
Physical Activity some forms of exercise. All individuals with peripheral
neuropathy should wear proper footwear and examine
Recommendations
their feet daily to detect lesions early. Anyone with a foot
5.26 Children and adolescents with type 1 or type 2 injury or open sore should be restricted to non–weight-
diabetes or prediabetes should engage in 60 bearing activities.
minutes/day or more of moderate- or vigorous-
intensity aerobic activity, with vigorous muscle- Autonomic Neuropathy
strengthening and bone-strengthening activities at
Individuals with diabetic autonomic neuropathy should
least 3 days/week. C
undergo cardiac investigation before beginning physical
5.27 Most adults with type 1 C and type 2 B diabetes
activity more intense than that to which they are accustomed.
should engage in 150 minutes or more of moderate-
to vigorous-intensity aerobic activity per week,
spread over at least 3 days/week, with no more than Diabetic Kidney Disease
2 consecutive days without activity. Shorter dura- Physical activity can acutely increase urinary albumin ex-
tions (minimum 75 minutes/week) of vigorous- cretion. However, there is no evidence that vigorous-intensity
exercise accelerates the rate of progression of diabetic kidney of disease progression are directly associated with reports
disease (DKD), and there appears to be no need for specific of diabetes distress.
exercise restrictions for people with DKD in general.
See “5. Facilitating Behavior Change and Well-Being to
Smoking Cessation: Tobacco and E-Cigarettes Improve Health Outcomes” in the complete 2021 Stan-
dards of Care for information on anxiety disorders (in-
Recommendations
cluding fear of hypoglycemia), depression, disordered
5.32 Advise all patients not to use cigarettes and other eating, and serious mental illness, as well as information
tobacco products A or e-cigarettes. A about referral to a mental health professional.
5.33 After identification of tobacco or e-cigarette use,
include smoking cessation counseling and other
forms of treatment as a routine component of di- 6. GLYCEMIC TARGETS
abetes care. A

Assessment of Glycemic Control
Psychosocial Issues Glycemic control is assessed by the A1C measurement,

continuous glucose monitoring (CGM), and self-
Recommendations monitoring of blood glucose (SMBG). Clinical trials
5.35 Psychosocial care should be integrated with a col- primarily use A1C as the metric to demonstrate the
laborative, patient-centered approach and provided benefits of improved glycemic control. CGM serves an
to all people with diabetes, with the goals of op- important role in assessing the effectiveness and safety of
timizing health outcomes and health-related quality treatment in many patients with type 1 diabetes, including
of life. A prevention of hypoglycemia, and in patients with type 2
5.36 Psychosocial screening and follow-up may include, diabetes on intensive insulin regimens and with hypo-
but are not limited to, attitudes about diabetes, glycemia. Patient SMBG can be used with self-
expectations for medical management and out- management and medication adjustment, particularly in
comes, affect or mood, general and diabetes-related individuals taking insulin.
quality of life, available resources (financial, social,
and emotional), and psychiatric history. E Glycemic Assessment
5.37 Providers should consider assessment for symptoms
Recommendations
of diabetes distress, depression, anxiety, disordered
eating, and cognitive capacities using appropriate 6.1 Assess glycemic status (A1C or other glycemic
standardized and validated tools at the initial visit, at measurement) at least two times a year in patients
periodic intervals, and when there is a change in who are meeting treatment goals (and who have
disease, treatment, or life circumstance. Including stable glycemic control). E
caregivers and family members in this assessment is 6.2 Assess glycemic status at least quarterly, and as
recommended. B needed, in patients whose therapy has recently

5.38 Consider screening older adults (aged $65 years) with changed and/or who are not meeting glycemic
diabetes for cognitive impairment and depression. B goals. E
Diabetes Distress Glucose Assessment by CGM

Recommendation Recommendations
5.39 Routinely monitor people with diabetes for 6.3 Standardized, single-page glucose reports from CGM
diabetes distress, particularly when treatment devices with visual cues, such as the ambulatory
targets are not met and/or at the onset of diabetes glucose profile (AGP), should be considered as a
complications. B standard printout for all CGM devices. E
Diabetes distress refers to significant negative psycho- 6.4 Time in range (TIR) is associated with the risk of
logical reactions related to emotional burdens and worries microvascular complications, should be an acceptable
specific to an individual’s experience in having to manage end point for clinical trials moving forward, and can be
a severe, complicated, and demanding chronic disease used for assessment of glycemic control. Additionally,
such as diabetes. The constant behavioral demands of time below target (,70 and ,54 mg/dL [3.9 and
diabetes self-management and the potential or actuality 3.0 mmol/L]) and time above target (.180 mg/dL

[10.0 mmol/L]) are useful parameters for reevalua- the goal of 7% may be acceptable, and even benefi-
tion of the treatment regimen. C cial, if it can be achieved safely without significant
For many people with diabetes, glucose monitoring is key hypoglycemia or other adverse effects of
for achieving glycemic targets. It allows patients to treatment. C
evaluate their individual response to therapy and 6.7 Less stringent A1C goals (such as ,8% [64
assess whether glycemic targets are being safely achieved. mmol/mol]) may be appropriate for patients with
limited life expectancy, or where the harms
CGM technology has grown rapidly and is more of treatment are greater than the benefits. B
accessible and accurate. The Glucose Management Reassess glycemic targets over time based on patient and
Indicator (GMI) and data on TIR, hypoglycemia, disease factors. (See Figure 6.2 and Table 12.1 in the
and hyperglycemia are available to providers and complete 2021 Standards of Care.) Table 6.3 summarizes
patients via standardized reports such as the AGP glycemic recommendations for many nonpregnant adults.

(Figure 6.1). Visual cues and recommendations are For specific guidance, see “6. Glycemic Targets,” “13.
offered to assist in data interpretation and treatment Children and Adolescents,” and “14. Management of
decision-making. Diabetes in Pregnancy” in the complete 2021 Standards
of Care.
Glycemic Goals
Recommendations Hypoglycemia
6.5a An A1C goal for many nonpregnant adults of ,7%
The classification of hypoglycemia level is defined in
(53 mmol/mol) without significant hypoglycemia is
Table 6.4.
appropriate. A
6.5b If using AGP/GMI to assess glycemia, a parallel goal
is a TIR of .70% with time below range ,4% Recommendations
(Figure 6.1). B 6.9 Occurrence and risk for hypoglycemia should be
6.6 On the basis of provider judgment and patient reviewed at every encounter and investigated as
preference, achievement of lower A1C levels than indicated. C
FIGURE 6.1 Key points included in standard AGP report. Adapted from Battelino T, Danne T, Bergenstal RM, et al. Diabetes Care 2019;42:
1593–1603.
6.10 Glucose (~15–20 g) is the preferred treatment for 6.13 Insulin-treated patients with hypoglycemia un-
the conscious individual with blood glucose ,70 awareness, one level 3 hypoglycemic event, or a
mg/dL (3.9 mmol/L), although any form of car- pattern of unexplained level 2 hypoglycemia should
bohydrate that contains glucose may be used. Fif- be advised to raise their glycemic targets to strictly
teen minutes after treatment, if SMBG shows avoid hypoglycemia for at least several weeks in
continued hypoglycemia, the treatment should be order to partially reverse hypoglycemia unaware-
repeated. Once the SMBG or glucose pattern is ness and reduce risk of future episodes. A
trending up, the individual should consume a meal 6.14 Ongoing assessment of cognitive function is sug-
or snack to prevent recurrence of hypoglycemia. B gested with increased vigilance for hypoglycemia by
6.11 Glucagon should be prescribed for all individuals at the clinician, patient, and caregivers if low cognition
increased risk of level 2 or 3 hypoglycemia so that it is or declining cognition is found. B
available should it be needed. Caregivers, school

personnel, or family members of these individuals
7. DIABETES TECHNOLOGY
should know where it is and when and how to
administer it. Glucagon administration is not limited Diabetes technology describes the devices, software, and
to health care professionals. E hardware used to manage diabetes. It includes delivery
6.12 Hypoglycemia unawareness or one or more episodes systems such as insulin pumps, pens, and syringes as well
of level 3 hypoglycemia should trigger hypoglycemia as CGM devices and glucose meters. Newer forms of
avoidance education and reevaluation of the diabetes technology include hybrid devices that both
treatment regimen. E monitor glucose and deliver insulin, sometimes via au-
tomated algorithms. Mobile applications and software
provide diabetes self-management support. Increased
patient interest has increased the use of diabetes tech-
TABLE 6.3 Summary of Glycemic Recommendations for
Many Nonpregnant Adults With Diabetes nology in the primary care setting.
A1C ,7.0% (53 mmol/mol)*# Recommendation

Preprandial capillary plasma 80–130 mg/dL* (4.4–7.2 mmol/L) 7.1 Use of technology should be individualized based on
glucose
a patient’s needs, desires, skill level, and availability
Peak postprandial capillary ,180 mg/dL* (10.0 mmol/L) of devices. E
plasma glucose†
SMBG
*More or less stringent glycemic goals may be appropriate for individual
patients. #CGM may be used to assess glycemic target as noted in Recommendations
Recommendation 6.5b and Figure 6.1. Goals should be individualized
7.2 People who are on insulin using SMBG should be
based on duration of diabetes, age/life expectancy, comorbid conditions,
known CVD or advanced microvascular complications, hypoglycemia encouraged to test when appropriate based on their
unawareness, and individual patient considerations. †Postprandial insulin regimen. This may include testing when
glucose may be targeted if A1C goals are not met despite reaching fasting, prior to meals and snacks, at bedtime, prior
preprandial glucose goals. Postprandial glucose measurements should be to exercise, when low blood glucose is suspected,
made 1–2 hours after the beginning of the meal, generally peak levels in
after treating low blood glucose until they are
patients with diabetes.
normoglycemic, and prior to and while performing
critical tasks such as driving. B
7.4 When prescribed as part of a DSMES program, SMBG
TABLE 6.4 Classification of Hypoglycemia may help to guide treatment decisions and/or self-
Glycemic Criteria/Description management for patients taking less frequent in-
sulin injections. B
Level 1 Glucose ,70 mg/dL (3.9 mmol/L) and $54 mg/dL (3.0
mmol/L)
CGM Devices
Level 2 Glucose ,54 mg/dL (3.0 mmol/L)
See Table 7.3 for definitions of types of CGM devices.
Level 3 A severe event characterized by altered mental and/or
physical status requiring assistance for treatment of
hypoglycemia Recommendations
Reprinted from Agiostratidou G, Anhalt H, Ball D, et al. Diabetes Care 7.11 In patients on a multiple daily injection (MDI) or
2017;40:1622–1630. continuous subcutaneous insulin infusion (CSII)

loss has been shown to improve glycemic control and

TABLE 7.3 CGM Devices
reduce the need for glucose-lowering medications.
Type of CGM Description
Real-time CGM CGM systems that measure and display glucose
levels continuously
Assessment
Intermittently scanned CGM systems that measure glucose levels

Recommendations
CGM continuously but only display glucose values 8.1 Use patient-centered, nonjudgmental language that
when swiped by a reader or a smartphone
fosters collaboration between patients and providers,
Professional CGM CGM devices that are placed on the patient in including people-first language (e.g., “person with
the provider’s office (or with remote instruction)
obesity” rather than “obese person”). E
and worn for a discrete period of time (generally
7–14 days). Data may be blinded or visible to 8.2 Measure height and weight and calculate BMI at
the person wearing the device. The data are annual visits or more frequently. Assess weight tra-

used to assess glycemic patterns and trends. jectory to inform treatment considerations. E
These devices are not fully owned by the
patient—they are a clinic-based device, as 8.3 Based on clinical considerations, such as the presence
opposed to the patient-owned real-time or of comorbid heart failure (HF) or significant unex-
intermittently scanned CGM devices. plained weight gain or loss, weight may need to be
monitored and evaluated more frequently. B If de-
regimen, real-time CGM devices should be used as terioration of medical status is associated with sig-
close to daily as possible for maximal benefit. A nificant weight gain or loss, inpatient evaluation
Intermittently scanned CGM devices should be should be considered, especially focused on associ-
scanned frequently, at a minimum once every 8 ations between medication use, food intake, and
hours. glycemic status. E
7.12 When used as an adjunct to pre- and postprandial 8.4 Accommodations should be made to provide privacy
SMBG, CGM can help to achieve A1C targets in during weighing. E
diabetes and pregnancy. B Use BMI to document weight status. Providers should
Data derived by CGM allows providers to analyze advise patients that higher BMIs increase the risks of
patient data using new metrics for glycemic targets. These diabetes, CVD, all-cause mortality, and adverse quality of
metrics include average blood glucose, percentage of life outcomes. Providers should assess patients’ readiness
TIR (70–180 mg/dL), glycemic variability, and percent- to engage in behavior changes for weight loss. Shared
age of time spent above and below range. decision-making should be used to determine behavioral
and weight-loss goals and patient-appropriate interven-
tion strategies.
Combined Insulin Pump and Sensor Systems
See “7. Diabetes Technology” in the complete 2021
Standards of Care for more information.
Diet, Physical Activity, and Behavioral Therapy
Recommendations
The Future
8.5 Diet, physical activity, and behavioral therapy
Diabetes technology must be adapted for the individual designed to achieve and maintain $5% weight loss is
needs of the patient. Education is essential to ensure that recommended for most patients with type 2 diabetes
patients can appropriately engage with their diabetes who have overweight or obesity and are ready to
devices to reap the potential health benefits. Both patients achieve weight loss. Greater benefits in control of
and providers must have realistic expectations and un- diabetes and CV risk may be gained from even
derstand the capabilities of these new technologies. greater weight loss. B
8.6 Such interventions should include a high frequency
of counseling ($16 sessions in 6 months) and focus
8. OBESITY MANAGEMENT FOR THE TREATMENT on dietary changes, physical activity, and behavioral
OF TYPE 2 DIABETES strategies to achieve a 500–750 kcal/day energy
Strong evidence exists that treatment of obesity can slow deficit. A
the progression of prediabetes to diabetes and benefit 8.7 An individual’s preferences, motivation, and life
those with type 2 diabetes. Modest and sustained weight circumstances should be considered, along with
medical status, when weight-loss interventions are insufficient (typically ,5% weight loss after 3 months’
recommended. C use), or if there are significant safety or tolerability
8.8 Behavioral changes that create an energy deficit, issues, consider discontinuation of the medication
regardless of macronutrient composition, will result and evaluate alternative medications or treatment
in weight loss. Dietary recommendations should be approaches. A
individualized to the patient’s preferences and Nearly all FDA-approved medications for weight loss have
nutritional needs. A been shown to improve glycemic control in patients with type
8.9 Evaluate systemic, structural, and socioeconomic
2 diabetes and delay progression to diabetes for those at risk.
factors that may impact dietary patterns and food Table 8.2 in the complete 2021 Standards of Care provides
choices, such as food insecurity and hunger, access to information on FDA-approved medications for obesity.
healthful food options, cultural circumstances, and
SDOH. C Given the high cost, limited insurance coverage, and

8.10 For patients who achieve short-term weight-loss paucity of data in people with diabetes, medical devices for
goals, long-term ($1 year) weight-maintenance weight loss are not considered to be the standard of care for
programs are recommended when available. Such obesity management in people with type 2 diabetes.
programs should, at minimum, provide monthly
contact and support, recommend ongoing monitoring Metabolic Surgery
of body weight (weekly or more frequently) and other Recommendations
self-monitoring strategies, and encourage high levels
8.16 Metabolic surgery should be a recommended option
of physical activity (200–300 minutes/week). A
8.11 Short-term dietary intervention using structured, to treat type 2 diabetes in screened surgical can-
very-low-calorie diets (800–1,000 kcal/day) may be didates with BMI $40 kg/m2 (BMI $37.5 kg/m2
prescribed for carefully selected patients by trained in Asian Americans) and in adults with BMI
practitioners in medical settings with close moni- 35.0–39.9 kg/m2 (32.5–37.4 kg/m2 in Asian
toring. Long-term, comprehensive weight- Americans) who do not achieve durable weight loss
maintenance strategies and counseling should be and improvement in comorbidities (including hy-
integrated to maintain weight loss. B perglycemia) with nonsurgical methods. A
8.17 Metabolic surgery may be considered as an option to
Among patients with both type 2 diabetes and overweight
treat type 2 diabetes in adults with BMI
or obesity who have inadequate glycemic, blood pressure,
30.0–34.9 kg/m2 (27.5–32.4 kg/m2 in Asian
and lipid control and/or other obesity-related medical
Americans) who do not achieve durable weight loss
conditions, modest and sustained weight loss improves
and improvement in comorbidities (including hy-
glycemic control, blood pressure, and lipids and may re-
perglycemia) with nonsurgical methods. A
duce the need for medications to control these risk factors.
8.18 Metabolic surgery should be performed in high-volume
centers with multidisciplinary teams knowledgeable
Pharmacotherapy about and experienced in the management of diabetes
Recommendations and gastrointestinal surgery. E
8.12 When choosing glucose-lowering medications for 8.19 Long-term lifestyle support and routine monitoring of
patients with type 2 diabetes and overweight or micronutrient and nutritional status must be provided
obesity, consider the medication’s effect on weight. B to patients after surgery, according to guidelines for
8.13 Whenever possible, minimize medications for postoperative management of metabolic surgery by
comorbid conditions that are associated with weight national and international professional societies. C
gain. E 8.20 People being considered for metabolic surgery should
8.14 Weight-loss medications are effective as adjuncts to
be evaluated for comorbid psychological conditions
diet, physical activity, and behavioral counseling for and social and situational circumstances that have the
selected patients with type 2 diabetes and BMI potential to interfere with surgery outcomes. B
$27 kg/m2. Potential benefits and risks must be 8.21 People who undergo metabolic surgery should rou-
considered. A tinely be evaluated to assess the need for ongoing
8.15 If a patient’s response to weight-loss medication mental health services to help with the adjustment to
is effective (typically defined as .5% weight loss medical and psychosocial changes after surgery. C
after 3 months’ use), further weight loss is likely A substantial body of evidence has now been accumu-
with continued use. When early response is lated, including data from numerous randomized

controlled (nonblinded) clinical trials, demonstrating 9.7 The early introduction of insulin should be con-
that metabolic surgery achieves superior glycemic control sidered if there is evidence of ongoing catabolism
and reduction of CV risk factors in patients with type 2 (weight loss), if symptoms of hyperglycemia are
diabetes and obesity compared with various lifestyle/ present, or when A1C levels (.10% [86 mmol/mol])
medical interventions. or blood glucose levels ($300 mg/dL [16.7
mmol/L]) are very high. E
Longer-term concerns include dumping syndrome 9.8 A patient-centered approach should be used to guide
(nausea, colic, and diarrhea), vitamin and mineral de- the choice of pharmacologic agents. Considerations
ficiencies, anemia, osteoporosis, and severe hypoglyce- include effect on CV and renal comorbidities,
mia. Long-term nutritional and micronutrient deficiencies efficacy, hypoglycemia risk, impact on weight,
and related complications occur with variable frequency cost, risk for side effects, and patient preferences
depending on the type of procedure and require lifelong (Table 9.1 and Figure 9.1). E
vitamin/nutritional supplementation; thus, long-term

9.9 Among patients with type 2 diabetes who have
lifestyle support and routine monitoring of micronutrient established atherosclerotic CVD (ASCVD) or indi-
and nutritional status should be provided to patients cators of high risk, established kidney disease, or HF, a
after surgery. sodium–glucose cotransporter 2 (SGLT2) inhibitor or
glucagon-like peptide 1 (GLP-1) receptor agonist with
demonstrated CVD benefit (Table 9.1) is recom-
9. PHARMACOLOGIC APPROACHES TO mended as part of the glucose-lowering regimen
GLYCEMIC TREATMENT independent of A1C and in consideration of patient-
Pharmacologic Therapy for Type 1 Diabetes specific factors. (See Figure 9.1 and “10. CVD AND
RISK MANAGEMENT.”) A
Recommendations
9.10 In patients with type 2 diabetes, a GLP-1
9.1 Most people with type 1 diabetes should be treated receptor agonist is preferred to insulin when
with MDI of prandial and basal insulin or CSII. A possible. A
9.2 Most individuals with type 1 diabetes should use rapid- 9.11 Recommendation for treatment intensification for
acting insulin analogs to reduce hypoglycemia risk. A patients not meeting treatment goals should not be
9.3 Patients with type 1 diabetes should receive education delayed. A
on how to match prandial insulin doses to carbohy- 9.12 The medication regimen and medication-taking
drate intake, premeal blood glucose, and anticipated behavior should be reevaluated at regular intervals
physical activity. C (every 3–6 months) and adjusted as needed to in-
See “9. Pharmacologic Approaches to Glycemic Treat- corporate specific factors that impact choice of
ment” in the complete 2021 Standards of Care for more treatment (Figure 4.1 and Table 9.1). E
detailed information on pharmacologic approaches to 9.13 Clinicians should be aware of the potential for
type 1 diabetes management. overbasalization with insulin therapy. Clinical sig-
nals that may prompt evaluation of overbasalization
Pharmacologic Therapy for Type 2 Diabetes include basal dose more than ~0.5 IU/kg, high
bedtime-morning or post-preprandial glucose dif-
Figure 9.1, Figure 9.2, and Table 9.1 provide details for
ferential, hypoglycemia (aware or unaware), and
informed decision-making on pharmacologic agents for
high variability. Indication of overbasalization
type 2 diabetes.
should prompt reevaluation to further individualize
therapy. E
Recommendations
9.4 Metformin is the preferred initial pharmacologic agent
for the treatment of type 2 diabetes. A
9.5 Once initiated, metformin should be continued as long
10. CVD AND RISK MANAGEMENT
as it is tolerated and not contraindicated; other ASCVD—defined as coronary heart disease (CHD), ce-
agents, including insulin, should be added to met- rebrovascular disease, or peripheral arterial disease
formin. A (PAD) presumed to be of atherosclerotic origin—is the
9.6 Early combination therapy can be considered in some leading cause of morbidity and mortality for people with
patients at treatment initiation to extend the time diabetes. HF is another major cause of morbidity and
to treatment failure. A mortality from CVD. For prevention and management of
VOLUME 39, NUMBER 1, WINTER 2021
FIGURE 9.1 Glucose-lowering medication in type 2 diabetes: 2021 ADA Professional Practice Committee adaptation of Davies MJ, D’Alessio DA, Fradkin J, et al. Diabetes Care 2018;41:
2669–2701 and Buse JB, Wexler DJ, Tsapas A, et al. Diabetes Care 2020;43:487–493. For appropriate context, see Figure 4.1. In this version, the “Indicators of high-risk or established
ASCVD, CKD, or HF” pathway was adapted based on trial populations studied. DPP-4i, DPP-4 inhibitor; GLP-1 RA, GLP-1 receptor agonist; LVEF, left ventricular ejection fraction; SGLT2i,
SGLT2 inhibitor; SU, sulfonylurea; T2D, type 2 diabates; TZD, thiazolidinedione.
27
FIGURE 9.2 Intensifying to injectable therapies. FPG, fasting plasma glucose; FRC, fixed-ratio combination; GLP-1 RA, GLP-1 receptor
agonist; max, maximum; PPG, postprandial glucose. Adapted from Davies MJ, D’Alessio DA, Fradkin J, et al. Diabetes Care 2018;41:
2669–2701.
TABLE 9.1 Drug-specific and patient factors to consider when selecting antihyperglycemic treatment in adults with type 2 diabetes
VOLUME 39, NUMBER 1, WINTER 2021

*For agent-specific dosing recommendations, please refer to the manufacturers’ prescribing information. †FDA-approved for CVD benefit. ‡FDA-approved for HF indication. §FDA-
29
approved for CKD indication. GI, gastrointestinal; GLP-1 RA, GLP-1 receptor agonist; NASH, nonalcoholic steatohepatitis; SQ, subcutaneous; T2D, type 2 diabetes.
both ASCVD and HF, CV risk factors should be assessed at indicated, a Dietary Approaches to Stop Hyper-
least annually in all patients with diabetes. These risk tension (DASH)-style eating pattern including re-
factors include obesity/overweight, hypertension, dysli- ducing sodium and increasing potassium intake,
pidemia, smoking, a family history of premature coronary moderation of alcohol intake, and increased physical
disease, chronic kidney disease (CKD), and the presence activity. A
of albuminuria.
The Risk Calculator Pharmacologic Interventions

The American College of Cardiology/American Heart Recommendations
Association ASCVD risk calculator (Risk Estimator Plus) 10.8 Patients with confirmed office-based blood
is a useful tool to estimate 10-year ASCVD risk pressure $140/90 mmHg should, in addition to
(tools.acc.org/ASCVD-Risk-Estimator-Plus). lifestyle therapy, have prompt initiation and timely

titration of pharmacologic therapy to achieve blood
Hypertension/Blood Pressure Control pressure goals. A
Hypertension, defined as a sustained blood 10.9 Patients with confirmed office-based blood
pressure $140/90 mmHg, is common among patients pressure $160/100 mmHg should, in addition to
with either type 1 or type 2 diabetes. lifestyle therapy, have prompt initiation and timely
titration of two drugs or a single-pill combination of
Recommendations drugs demonstrated to reduce CV events in patients
with diabetes. A
Screening and Diagnosis 10.10 Treatment for hypertension should include drug
10.1 Blood pressure should be measured at every routine classes demonstrated to reduce CV events in pa-
clinical visit. Patients found to have elevated blood tients with diabetes. A ACE inhibitors or angio-
pressure ($140/90 mmHg) should have blood tensin receptor blockers (ARBs) are recommended
pressure confirmed using multiple readings, in- first-line therapy for hypertension in people with
cluding measurements on a separate day, to diagnose diabetes and coronary artery disease (CAD). A
hypertension. B 10.11 Multiple-drug therapy is generally required to
10.2 All hypertensive patients with diabetes should achieve blood pressure targets. However, combi-
monitor their blood pressure at home. B nations of ACE inhibitors and ARBs and combi-
nations of ACE inhibitors or ARBs with direct renin
Treatment Goals inhibitors should not be used. A
10.12 An ACE inhibitor or ARB, at the maximum
10.3 For patients with diabetes and hypertension, blood
pressure targets should be individualized through a tolerated dose indicated for blood pressure treat-
shared decision-making process that addresses CV ment, is the recommended first-line treatment for
risk, potential adverse effects of antihypertensive hypertension in patients with diabetes and urinary
medications, and patient preferences. C albumin-to-creatinine ratio (UACR) $300 mg/g
10.4 For individuals with diabetes and hypertension at
creatinine A or 30–299 mg/g creatinine. B If one
higher CV risk (existing ASCVD or 10-year ASCVD class is not tolerated, the other should be
risk $15%), a blood pressure target of ,130/80 substituted. B
10.13 For patients treated with an ACE inhibitor, ARB, or
mmHg may be appropriate, if it can be safely
attained. C diuretic, serum creatinine/estimated glomerular
10.5 For individuals with diabetes and hypertension at
filtration rate (eGFR) and serum potassium levels
lower risk for CVD (10-year ASCVD risk ,15%), should be monitored at least annually. B
10.14 Patients with hypertension who are not meeting
treat to a blood pressure target of ,140/90 mmHg. A
blood pressure targets on three classes of antihy-
pertensive medications (including a diuretic)
Treatment Strategies
should be considered for mineralocorticoid re-
Lifestyle Intervention ceptor antagonist therapy. B
Recommendation Multiple-drug therapy is often required to achieve blood
10.7 For patients with blood pressure .120/80 mmHg, pressure targets, particularly in the setting of DKD. Titration
lifestyle intervention consists of weight loss when of and/or addition of further blood pressure medications
should be made in a timely fashion to overcome therapeutic ezetimibe to maximally tolerated statin therapy to
inertia in achieving blood pressure goals. (See Figure 10.1 in reduce LDL cholesterol levels by 50% or more. C
the complete 2021 Standards of Care.)
Lipid Management Secondary Prevention
Lifestyle Intervention Recommendations

Recommendations 10.23 For patients of all ages with diabetes and ASCVD,
10.15 Lifestyle modification focusing on weight loss (if high-intensity statin therapy should be added to
indicated); application of a Mediterranean style or lifestyle therapy. A
10.24 For patients with diabetes and ASCVD considered
DASH eating pattern; reduction of saturated fat and
trans fat; increase of dietary n-3 fatty acids, viscous very high risk using specific criteria, if LDL cholesterol
fiber, and plant stanols/sterols intake; and increased is $70 mg/dL on maximally tolerated statin dose,

physical activity should be recommended to improve consider adding additional LDL-lowering therapy
the lipid profile and reduce the risk of developing (such as ezetimibe or PCSK9 inhibitor). A Ezetimibe
ASCVD in patients with diabetes. A may be preferred due to lower cost.
10.25 For patients who do not tolerate the intended
10.16 Intensify lifestyle therapy and optimize glycemic
control for patients with elevated triglyceride levels intensity, the maximally tolerated statin dose
($150 mg/dL [1.7 mmol/L]) and/or low HDL should be used. E
cholesterol (,40 mg/dL [1.0 mmol/L] for 10.26 In adults with diabetes aged .75 years already on
men, ,50 mg/dL [1.3 mmol/L] for women). C statin therapy, it is reasonable to continue statin
treatment. B
Ongoing Therapy and Monitoring With Lipid Panel 10.27 In adults with diabetes aged .75 years, it may be
Recommendations reasonable to initiate statin therapy after discussion
10.17 In adults not taking statins or other lipid-lowering of potential benefits and risks. C
therapy, it is reasonable to obtain a lipid profile at the 10.28 Statin therapy is contraindicated in pregnancy. B
time of diabetes diagnosis, at an initial medical Patients with type 2 diabetes have an increased prevalence of
evaluation, and every 5 years thereafter if under the lipid abnormalities, contributing to their high risk of ASCVD.
age of 40 years, or more frequently if indicated. E Multiple clinical trials have demonstrated the beneficial effects
10.18 Obtain a lipid profile at initiation of statins or other of statin therapy on ASCVD outcomes in subjects with and
lipid-lowering therapy, 4–12 weeks after initiation without CHD. Statins are the drugs of choice for LDL cho-
or a change in dose, and annually thereafter as it lesterol lowering and cardioprotection. High-intensity statin
may help to monitor the response to therapy and therapy will achieve a reduction of approximately $50% in
inform medication adherence. E LDL cholesterol, and moderate-intensity statin regimens
achieve 30–49% reductions in LDL cholesterol.
Statin Treatment
Primary Prevention Treatment of Other Lipoprotein Fractions or Targets
Recommendations Recommendations
10.19 For patients with diabetes aged 40–75 years 10.29 For patients with fasting triglyceride levels $500
without ASCVD, use moderate-intensity statin mg/dL, evaluate for secondary causes of hyper-
therapy in addition to lifestyle therapy. A triglyceridemia and consider medical therapy to
10.20 For patients with diabetes aged 20–39 years with reduce the risk of pancreatitis. C
additional ASCVD risk factors, it may be reasonable 10.30 In adults with moderate hypertriglyceridemia
to initiate statin therapy in addition to lifestyle (fasting or nonfasting triglycerides 175–499 mg/dL),
therapy. C clinicians should address and treat lifestyle factors
10.21 In patients with diabetes at higher risk, especially (obesity and metabolic syndrome), secondary factors
those with multiple ASCVD risk factors or aged (diabetes, chronic liver or kidney disease and/or
50–70 years, it is reasonable to use high-intensity nephrotic syndrome, hypothyroidism), and medi-
statin therapy. B cations that raise triglycerides. C
10.22 In adults with diabetes and 10-year ASCVD risk of 10.31 In patients with ASCVD or other CV risk factors on a
20% or higher, it may be reasonable to add statin with controlled LDL cholesterol but elevated

triglycerides (135–499 mg/dL), the addition of stable coronary and/or PAD and low bleeding risk
icosapent ethyl can be considered to reduce CV to prevent major adverse limb and CV events. A
risk. A 10.39 Aspirin therapy (75–162 mg/day) may be con-
sidered as a primary prevention strategy in those
Other Combination Therapy with diabetes who are at increased CV risk, after a
comprehensive discussion with the patient on the
Recommendations
benefits versus the comparable increased risk of
10.32 Statin plus fibrate combination therapy has not bleeding. A
been shown to improve ASCVD outcomes and is
generally not recommended. A Risk Reduction
10.33 Statin plus niacin combination therapy has not been Aspirin is effective in reducing CV morbidity and mortality
shown to provide additional CV benefit above statin in high-risk patients with previous myocardial infarction

therapy alone, may increase the risk of stroke with (MI) or stroke (secondary prevention) and is strongly
additional side effects, and is generally not rec- recommended.
ommended. A
In primary prevention, however, the benefit is more
controversial. The use of aspirin needs to be carefully
Diabetes Risk With Statin Use considered in the context of shared decision-making,
A meta-analysis of 13 randomized statin trials with 91,140 weighing the CV benefits with the fairly comparable
participants showed an odds ratio of 1.09 for a new increase in risk of bleeding; generally, it may not be
diagnosis of diabetes, so that (on average) treatment of recommended. Aspirin may be considered in the context
255 patients with statins for 4 years resulted in one of high CV risk with low bleeding risk, but generally not
additional case of diabetes while simultaneously pre- in older adults. Aspirin is not recommended for those
venting 5.4 vascular events among those 255 patients. at low risk of ASCVD (such as men and women
aged ,50 years with diabetes with no other major ASCVD
risk factors) as the low benefit is likely to be outweighed
Lipid-Lowering Agents and Cognitive Function
by the risks of bleeding. The risks and benefits of
The most recent systematic review of the FDA’s post- dual antiplatelet or antiplatelet plus anticoagulant
marketing surveillance databases, randomized controlled treatment strategies should be thoroughly discussed with
trials, and cohort, case-control, and cross-sectional studies eligible patients.
evaluating cognition in patients receiving statins found
that published data do not reveal an adverse effect of CVD
statins on cognition. Recommendations
Screening
Antiplatelet Agents
10.40 In asymptomatic patients, routine screening for
Recommendations
CAD is not recommended, as it does not improve
10.34 Use aspirin therapy (75–162 mg/day) as a sec- outcomes as long as ASCVD risk factors are
ondary prevention strategy in those with diabetes treated. A
and a history of ASCVD. A 10.41 Consider investigations for CAD in the presence of
10.35 For patients with ASCVD and documented aspirin any of the following: atypical cardiac symptoms
allergy, clopidogrel (75 mg/day) should be used. B (e.g., unexplained dyspnea, chest discomfort);
10.36 Dual antiplatelet therapy (with low-dose aspirin signs or symptoms of associated vascular disease,
and a P2Y12 inhibitor) is reasonable for a year after including carotid bruits, transient ischemic attack,
an acute coronary syndrome and may have benefits stroke, claudication, or PAD; or electrocardiogram
beyond this period. A abnormalities (e.g., Q waves). E
10.37 Long-term treatment with dual antiplatelet therapy
should be considered for patients with prior cor-
onary intervention, high ischemic risk, and low Treatment
bleeding risk to prevent major adverse CV events 10.42 Among patients with type 2 diabetes who have
(MACE). A established ASCVD or established kidney disease, an
10.38 Combination therapy with aspirin plus low-dose SGLT2 inhibitor or GLP-1 receptor agonist with
rivaroxaban should be considered for patients with demonstrated CVD benefit (see Tables 10.3B and
10.3C in the complete 2021 Standards of Care) is risk factors for ASCVD, a GLP-1 receptor agonist with
recommended as part of the comprehensive CV risk demonstrated CV benefit is recommended to reduce the
reduction and/or glucose-lowering regimens. A risk of MACE. For many patients, use of either an SGLT2
10.42a In patients with type 2 diabetes and established inhibitor or a GLP-1 receptor agonist to reduce CV risk is
ASCVD, multiple ASCVD risk factors, or DKD, an appropriate. It is unknown whether use of both classes of
SGLT2 inhibitor with demonstrated CV benefit is drugs will provide an additive CV outcomes benefit. In
recommended to reduce the risk of MACE and/or patients with type 2 diabetes and established HFrEF, an
HF hospitalization. A SGLT2 inhibitor with proven benefit in this patient
10.42b In patients with type 2 diabetes and established population is recommended to reduce the risk of wors-
ASCVD or multiple risk factors for ASCVD, a ening HF and CV death.
GLP-1 receptor agonist with demonstrated CV
benefit is recommended to reduce the risk of 11. MICROVASCULAR COMPLICATIONS AND

MACE. A FOOT CARE
10.43 In patients with type 2 diabetes and established HF
with reduced ejection fraction (HFrEF), an SGLT2
CKD
inhibitor with proven benefit in this patient Recommendations
population is recommended to reduce risk of Screening
worsening HF and CV death. A
11.1a At least annually, urinary albumin (e.g., spot
10.44 In patients with known ASCVD, particularly CAD,
ACE inhibitor or ARB therapy is recommended to UACR) and eGFR should be assessed in patients
reduce the risk of CV events. A with type 1 diabetes with duration of $5 years
10.45 In patients with prior MI, b-blockers should be
and in all patients with type 2 diabetes
continued for 3 years after the event. B regardless of treatment. B
11.1b Patients with diabetes and urinary albumin .300
10.46 Treatment of patients with HFrEF should include a
b-blocker with proven CV outcomes benefit, unless mg/g creatinine and/or an eGFR 30–60 mL/min/
otherwise contraindicated. A 1.73 m2 should be monitored twice annually to
10.47 In patients with type 2 diabetes with stable HF,
guide therapy. B
metformin may be continued for glucose lowering
if eGFR remains .30 mL/min/1.73 m2 but should Treatment
be avoided in unstable or hospitalized patients 11.2 Optimize glucose control to reduce the risk or slow
with HF. B the progression of CKD. A
11.3a For patients with type 2 diabetes and DKD, consider
CV outcomes trials (CVOTs) of dipeptidyl peptidase 4
(DPP-4) inhibitors have all, so far, not shown CV benefits use of an SGLT2 inhibitor in patients with an
relative to placebo. Numerous large randomized con- eGFR $30 mL/min/1.73 m2 and urinary albu-
trolled trials have reported statistically significant re- min .300 mg/g creatinine. A
11.3b In patients with type 2 diabetes and DKD, consider
ductions in CV events for three of the FDA-approved
SGLT2 inhibitors (empagliflozin, canagliflozin, and use of SGLT2 inhibitors additionally for CV risk
dapagliflozin) and four FDA-approved GLP-1 receptor reduction when eGFR and urinary albumin cre-
agonists (liraglutide, albiglutide [although that agent was atinine are $30 mL/min/1.73 m2 or .300 mg/g,
removed from the market for business reasons], sem- respectively. A
11.3c In patients with CKD who are at increased risk for
aglutide [lower risk of CV events in a moderate-sized
clinical trial but one not powered as a CVOT], and CV events, use of a GLP-1 receptor agonist reduces
dulaglutide). SGLT2 inhibitors also appear to reduce risk renal end points, primarily albuminuria, progres-
of HF hospitalization and progression of kidney disease in sion of albuminuria, and CV events (Table 9.1). A
11.4 Optimize blood pressure control to reduce the risk
patients with established ASCVD, multiple risk factors for
or slow the progression of CKD. A
ASCVD, or DKD.
11.5 Do not discontinue renin-angiotensin system
In patients with type 2 diabetes and established ASCVD, blockade for minor increases in serum creatinine
multiple ASCVD risk factors, or DKD, an SGLT2 inhibitor (,30%) in the absence of volume depletion. A
with demonstrated CV benefit is recommended to reduce 11.6 For people with nondialysis-dependent CKD, die-
the risk of MACE and/or HF hospitalization. In patients tary protein intake should be ~0.8 g/kg body
with type 2 diabetes and established ASCVD or multiple weight per day (the recommended daily

allowance). A For patients on dialysis, higher levels Epidemiology of Diabetes and CKD
of dietary protein intake should be considered, since CKD is diagnosed by the persistent presence of elevated
malnutrition is a major problem in some dialysis urinary albumin excretion (albuminuria), low eGFR, or
patients. B other manifestations of kidney damage (Figure 11.1).
11.7 In nonpregnant patients with diabetes and hy- Among people with type 1 or type 2 diabetes, the presence
pertension, either an ACE inhibitor or an ARB is of CKD markedly increases CV risk and health care costs.
recommended for those with modestly elevated
UACR (30–299 mg/g creatinine) B and is
strongly recommended for those with UACR Selection of Glucose-Lowering Medications for
$300 mg/g creatinine and/or eGFR ,60 mL/min/ Patients With CKD
1.73 m2. A For patients with type 2 diabetes and established CKD,
11.8 Periodically monitor serum creatinine and potas- special considerations for the selection of glucose-

sium levels for the development of increased lowering medications include limitations to available
creatinine or changes in potassium when ACE inhib- medications when eGFR is diminished and a desire to
itors, ARBs, or diuretics are used. B mitigate high risks of CKD progression, CVD, and hy-
11.9 An ACE inhibitor or an ARB is not recommended for poglycemia. Drug dosing may require modification with
the primary prevention of CKD in patients with di- eGFR ,60 mL/min/1.73 m2.
abetes who have normal blood pressure, normal
UACR (,30 mg/g creatinine), and normal eGFR. A Metformin is contraindicated in patients with an
11.10 Patients should be referred for evaluation by a eGFR ,30 mL/min/1.73 m2; eGFR should be monitored
nephrologist if they have an eGFR ,30 mL/min/ while taking metformin; the benefits and risks of con-
1.73 m2. A tinuing treatment should be reassessed when eGFR falls
11.11 Promptly refer to a physician experienced in to ,45 mL/min/1.73 m2; metformin should not be ini-
the care of kidney disease for uncertainty about tiated for patients with an eGFR ,45 mL/min/1.73 m2;
the etiology of kidney disease, difficult manage- and metformin should be temporarily discontinued at the
ment issues, and rapidly progressing kidney time of or before iodinated contrast imaging procedures in
disease. A patients with eGFR of 30–60 mL/min/1.73 m2.
FIGURE 11.1 Risk of CKD progression,

frequency of visits, and referral to
nephrology according to glomerular
filtration rate (GFR) and albuminuria.
The GFR and albuminuria grid depicts
the risk of progression, morbidity, and
mortality by color, from best to worst
(green, yellow, orange, red, dark red).
The numbers in the boxes are a guide to
the frequency of visits (number of times
per year). Green can reflect CKD with
normal eGFR and albumin-to-
creatinine ratio only in the presence
of other markers of kidney damage,
such as imaging showing polycystic
kidney disease or kidney biopsy
abnormalities, with follow-up
measurements annually; yellow
requires caution and measurements at
least once per year; orange requires
measurements twice per year; red
requires measurements three times
per year; and dark red requires
measurements four times per year.
These are general parameters only, based on expert opinion, and underlying comorbid conditions and disease state as well as the likelihood
of impacting a change in management for any individual patient must be taken into account. “Refer” indicates that nephrology services are
recommended. *Referring clinicians may wish to discuss with their nephrology service, depending on local arrangements regarding
treating or referring. Reprinted with permission from Vassalotti JA, Centor R, Turner BJ, Greer RC, Choi M, Sequist TD; National Kidney
Foundation Kidney Disease Outcomes Quality Initiative. Am J Med 2016;129:153–162.e7.
SGLT2 inhibitors and GLP-1 receptor agonists should subsequent dilated retinal examinations should be
be considered for patients with type 2 diabetes and repeated at least annually by an ophthalmologist or
CKD who require another drug added to metformin to optometrist. If retinopathy is progressing or sight-
attain target A1C or cannot use or tolerate metformin. threatening, then examinations will be required
SGLT2 inhibitors reduce risks of CKD progression, CVD more frequently. B
events, and hypoglycemia. GLP-1 receptor agonists 11.17 Programs that use retinal photography (with remote
are suggested because they reduce risks of CVD reading or use of a validated assessment tool) to
events and hypoglycemia and appear to possibly slow improve access to diabetic retinopathy screening can
CKD progression. be appropriate screening strategies for diabetic
retinopathy. Such programs need to provide path-
For patients with type 2 diabetes and CKD, the selection of
ways for timely referral for a comprehensive
specific agents may depend on comorbidity and CKD
eye examination when indicated. B
stage. SGLT2 inhibitors may be more useful for patients at

11.18 Women with preexisting type 1 or type 2
high risk of CKD progression (i.e., with albuminuria or a
diabetes who are planning pregnancy or who are
history of documented eGFR loss) (Figure 9.1) because
pregnant should be counseled on the risk of de-
they appear to have large beneficial effects on CKD in-
velopment and/or progression of diabetic reti-
cidence. The SGLT2 inhibitors empagliflozin and dapa-
nopathy. B
gliflozin are approved by the FDA for use with
11.19 Eye examinations should occur before pregnancy or
eGFR $45 mL/min/1.73 m2.
in the first trimester in patients with preexisting
type 1 or type 2 diabetes, and then patients should
CVD and Blood Pressure be monitored every trimester and for 1 year
Hypertension is a strong risk factor for the development postpartum as indicated by the degree of reti-
and progression of CKD. Two clinical trials studied the nopathy. B
combinations of ACE inhibitors and ARBs and found no
benefits on CVD or CKD, and the drug combination had
higher adverse event rates (hyperkalemia and/or acute Treatment
kidney injury). Therefore, the combined use of ACE in- 11.20 Promptly refer patients with any level of macular
hibitors and ARBs should be avoided. edema, severe nonproliferative diabetic retinopa-
thy (a precursor of proliferative diabetic retinop-
Diabetic Retinopathy athy), or any proliferative diabetic retinopathy to
an ophthalmologist who is knowledgeable and
Recommendations
experienced in the management of diabetic reti-
11.12 Optimize glycemic control to reduce the risk or slow nopathy. A
the progression of diabetic retinopathy. A 11.21 The traditional standard treatment, panretinal laser
11.13 Optimize blood pressure and serum lipid control to photocoagulation therapy, is indicated to reduce the
reduce the risk or slow the progression of diabetic risk of vision loss in patients with high-risk prolif-
retinopathy. A erative diabetic retinopathy and, in some cases, se-
vere nonproliferative diabetic retinopathy. A
11.24 The presence of retinopathy is not a contraindi-
Screening
cation to aspirin therapy for cardioprotection,
11.14 Adults with type 1 diabetes should have an initial as aspirin does not increase the risk of retinal
dilated and comprehensive eye examination by an hemorrhage. A
ophthalmologist or optometrist within 5 years after
the onset of diabetes. B
11.15 Patients with type 2 diabetes should have an initial Neuropathy
dilated and comprehensive eye examination by an Recommendations
ophthalmologist or optometrist at the time of the
diabetes diagnosis. B Screening
11.16 If there is no evidence of retinopathy for one or more 11.25 All patients should be assessed for diabetic pe-
annual eye exams and glycemia is well controlled, ripheral neuropathy starting at diagnosis of type 2
then screening every 1–2 years may be considered. If diabetes and 5 years after the diagnosis of type 1
any level of diabetic retinopathy is present, diabetes and at least annually thereafter. B

11.26 Assessment for distal symmetric polyneuropathy 11.36 A multidisciplinary approach is recommended
should include a careful history and assessment of for individuals with foot ulcers and high-risk
either temperature or pinprick sensation (small feet (e.g., dialysis patients and those
fiber function) and vibration sensation using a with Charcot foot or prior ulcers or
128-Hz tuning fork (for large-fiber function). All amputation). B
patients should have annual 10-g monofilament 11.37 Refer patients who smoke or who have histories of
testing to identify feet at risk for ulceration and prior lower-extremity complications, loss of pro-
amputation. B tective sensation, structural abnormalities, or PAD
11.27 Symptoms and signs of autonomic neuropathy to foot care specialists for ongoing preventive care
should be assessed in patients with microvascular and lifelong surveillance. C
complications. E 11.38 Provide general preventive foot self-care education
to all patients with diabetes. B

11.39 The use of specialized therapeutic footwear is
Treatment recommended for high-risk patients with
11.28 Optimize glucose control to prevent or delay the diabetes, including those with severe
development of neuropathy in patients with type 1 neuropathy, foot deformities, ulcers, callous
diabetes A and to slow the progression of neu- formation, poor peripheral circulation, or history
ropathy in patients with type 2 diabetes. B of amputation. B
11.29 Assess and treat patients to reduce pain related to Foot ulcers and amputation are consequences of
diabetic peripheral neuropathy B and symptoms of diabetic neuropathy and PAD. Early recognition
autonomic neuropathy and to improve quality of and treatment of patients at risk can delay or
life. E prevent adverse outcomes. See “11. Microvascular
11.30 Pregabalin, duloxetine, or gabapentin are recom- Complications and Foot Care” in the complete 2021
mended as initial pharmacologic treatments for Standards of Care for specifics regarding comprehensive
neuropathic pain in diabetes. A foot exams.
12. OLDER ADULTS

Foot Care
Recommendations Recommendations
12.1 Consider the assessment of medical, psychological,
11.31 Perform a comprehensive foot evaluation at least
annually to identify risk factors for ulcers and functional (self-management abilities), and social
amputations. B geriatric domains in older adults to provide a
11.32 Patients with evidence of sensory loss or prior framework to determine targets and therapeutic
ulceration or amputation should have their feet approaches for diabetes management. B
inspected at every visit. B 12.2 Screen for geriatric syndromes (i.e., polypharmacy,
11.33 Obtain a prior history of ulceration, amputation, cognitive impairment, depression, urinary inconti-
Charcot foot, angioplasty or vascular surgery, nence, falls, and persistent pain) in older adults, as
cigarette smoking, retinopathy, and renal disease they may affect diabetes self-management and di-
and assess current symptoms of neuropathy (pain, minish quality of life. B
burning, numbness) and vascular disease (leg More than one-fourth of people over the age of 65 years
fatigue, claudication). B have diabetes and one-half of older adults have predi-
11.34 The examination should include inspection of the abetes. Diabetes management in older adults requires
skin, assessment of foot deformities, neurological regular assessment of medical, psychological, functional,
assessment (10-g monofilament testing with at and social domains. Older adults with diabetes have
least one other assessment: pinprick, temperature, higher rates of premature death, functional disability,
vibration), and vascular assessment including accelerated muscle loss, and coexisting illnesses, such as
pulses in the legs and feet. B hypertension, CHD, and stroke, than older adults without
11.35 Patients with symptoms of claudication or de- diabetes. Screening for diabetes complications in older
creased or absent pedal pulses should be referred adults should be individualized and periodically revisited,
for ankle-brachial index and for further vascular as the results of screening tests may impact targets and
assessment as appropriate. C therapeutic approaches.
Neurocognitive Function 12.8 Screening for diabetes complications should be

individualized in older adults. Particular attention
Recommendation
should be paid to complications that would lead to
12.3 Screening for early detection of mild cognitive functional impairment. C
impairment or dementia should be performed for 12.9 Treatment of hypertension to individualized target
adults 65 years of age or older at the initial visit and levels is indicated in most older adults. C
annually as appropriate. B 12.10 Treatment of other CV risk factors should be indi-
Older adults with diabetes are at higher risk of institu- vidualized in older adults considering the time frame
tionalization and cognitive impairment, which can make it of benefit. Lipid-lowering therapy and aspirin
challenging for clinicians to help their patients reach therapy may benefit those with life expectancies at
individualized glycemic, blood pressure, and lipid targets. least equal to the time frame of primary prevention
People with diabetes have higher incidences of all-cause or secondary intervention trials. E

dementia, Alzheimer disease, and vascular dementia than Providers caring for older adults with diabetes must take
people with normal glucose tolerance. clinical, cognitive, and functional heterogeneity into
consideration when setting and prioritizing treatment
goals. (See Table 12.1 in the complete 2021 Standards of
Hypoglycemia Care.) Patients who can be expected to live long enough to
Recommendations reap the benefits of long-term intensive diabetes man-
12.4 Because older adults with diabetes have a greater agement, who have good cognitive and physical function,
risk of hypoglycemia than younger adults, episodes and who choose to do so via shared decision-making may
of hypoglycemia should be ascertained and be treated using therapeutic interventions and goals
addressed at routine visits. B similar to those for younger adults with diabetes.
12.5 For older adults with type 1 diabetes, CGM should be
considered to reduce hypoglycemia. A Lifestyle Management
Older adults are at higher risk of hypoglycemia for many Recommendations
reasons, including insulin deficiency necessitating insulin 12.11 Optimal nutrition and protein intake is recom-
therapy and progressive renal insufficiency. Glycemic mended for older adults; regular exercise, in-
targets and pharmacologic regimens may need to be cluding aerobic activity, weight-bearing exercise,
adjusted to minimize the occurrence of hypoglycemic and/or resistance training, should be encouraged
events. Patients and their caregivers should be routinely in all older adults who can safely engage in such
queried about hypoglycemia and hypoglycemia activities. B
unawareness. 12.12 For older adults with type 2 diabetes, overweight/
obesity, and capacity to safely exercise, an intensive
lifestyle intervention focused on dietary changes,
Treatment Goals physical activity, and modest weight loss (e.g.,
5–7%) should be considered for its benefits on
Recommendations
quality of life, mobility and physical functioning,
12.6 Older adults who are otherwise healthy with few and cardiometabolic risk factor control. A
coexisting chronic illnesses and intact cognitive
function and functional status should have lower Pharmacologic Therapy
glycemic goals (such as A1C ,7.0–7.5% [53–58
mmol/mol]), while those with multiple coexisting Recommendations
chronic illnesses, cognitive impairment, or func- 12.13 In older adults with type 2 diabetes at increased risk
tional dependence should have less stringent of hypoglycemia, medication classes with low risk
glycemic goals (such as A1C ,8.0–8.5% [64–69 of hypoglycemia are preferred. B
mmol/mol]). C 12.14 Overtreatment of diabetes is common in older
12.7 Glycemic goals for some older adults might rea- adults and should be avoided. B
sonably be relaxed as part of individualized care, 12.15 Deintensification (or simplification) of complex
but hyperglycemia leading to symptoms or risk of regimens is recommended to reduce the risk of
acute hyperglycemia complications should be hypoglycemia and polypharmacy, if it can be
avoided in all patients. C achieved within the individualized A1C target. B

12.16 Consider costs of care and insurance coverage rules glucose and blood pressure control may not be
when developing treatment plans in order to reduce necessary E, and reduction of therapy may be ap-
risk of cost-related nonadherence. B propriate. Similarly, the intensity of lipid manage-
Special care is required in prescribing and monitoring ment can be relaxed, and withdrawal of lipid-
pharmacologic therapies in older adults. Metformin is the lowering therapy may be appropriate. A
first-line agent for older adults with type 2 diabetes. See 12.20 Overall comfort, prevention of distressing symp-
Figure 9.1 for general recommendations regarding toms, and preservation of quality of life and dignity
glucose-lowering treatment for adults with type 2 dia- are primary goals for diabetes management at the
betes and Table 9.1 for patient- and drug-specific factors to end of life. C
consider when selecting glucose-lowering agents. Overall, palliative medicine promotes comfort, symptom
control and prevention (pain, hypoglycemia, hypergly-
The needs of older adults with diabetes and their caregivers
cemia, and dehydration), and preservation of dignity and

should be evaluated to construct a tailored care plan.
quality of life in patients with limited life expectancy. Strict
Due in part to the success of modern diabetes manage- glucose and blood pressure control may not be consistent
ment, patients with type 1 diabetes are living longer, and with achieving comfort and quality of life. Glucose targets
the population of these patients .65 years of age is should aim to prevent hypoglycemia and hyperglycemia.
growing. Some of these patients may be using insulin Different patient categories, including stable patients,
pumps and/or CGM systems. To avoid DKA, older adults patients with organ failure, and dying patients, have been
with type 1 diabetes need some form of basal insulin even proposed for diabetes management in those with ad-
when they are unable to ingest meals. vanced disease.
Treatment in Skilled Nursing Facilities and

Nursing Homes 13. CHILDREN AND ADOLESCENTS
Recommendations The management of diabetes in children and adolescents
12.17 Consider diabetes education for the staff of long- cannot simply be derived from care routinely provided
term care (LTC) and rehabilitation facilities to to adults with diabetes. The epidemiology, pathophysi-
improve the management of older adults with ology, developmental considerations, and response to
diabetes. E therapy in pediatric-onset diabetes are different from
12.18 Patients with diabetes residing in LTC facilities need adult diabetes.
careful assessment to establish individualized
See “13. Children and Adolescents” in the complete 2021
glycemic goals and to make appropriate choices of
Standards of Care for specific recommendations regarding
glucose-lowering agents based on their clinical and
the treatment of type 1 diabetes in this group, as well as the
functional status. E
comprehensive treatment of children with type 2 diabetes,
Management of diabetes is unique in the LTC setting. including screening, prevention and management of CV risk
Special management considerations include the need to factors, microvascular complications, and other associated
avoid both hypoglycemia and the complications of hy- conditions. See “7. Diabetes Technology” in the complete
perglycemia. Older adults with diabetes in LTC are es- 2021 Standards of Care for more information on the use of
pecially vulnerable to hypoglycemia. blood glucose meters, CGM, and insulin pumps. The ADA
An older adult residing in an LTC facility may have ir- position statements “Type 1 Diabetes in Children and
regular and unpredictable meal consumption, under- Adolescents” and “Evaluation and Management of Youth-
nutrition, anorexia, and impaired swallowing. Diets Onset Type 2 Diabetes” offer additional information.
tailored to patients’ culture, preferences, and personal
goals may increase quality of life, satisfaction with meals, Type 1 Diabetes
and nutrition status.
Type 1 diabetes is the most common form of diabetes in youth.
End-of-Life Care The provider must consider the unique aspects of care and
management of children and adolescents with type 1 dia-
Recommendations betes. A multidisciplinary team of specialists trained in pe-
12.19 When palliative care is needed in older adults with diatric diabetes management and sensitive to the challenges
diabetes, providers should initiate conversations of children and adolescents with type 1 diabetes and their
regarding the goals and intensity of care. Strict families should provide care for this population.
Type 2 Diabetes 13.67 Youth with marked hyperglycemia (blood glucose

$250 mg/dL [13.9 mmol/L], A1C $8.5% [69
Type 2 diabetes in youth has increased over the past
mmol/mol]) without acidosis at diagnosis who
20 years, and recent estimates suggest an incidence of
are symptomatic with polyuria, polydipsia, nocturia,
~5,000 new cases per year in the U.S. Evidence suggests
and/or weight loss should be treated initially with
that type 2 diabetes in youth is different not only from
basal insulin while metformin is initiated and
type 1 diabetes, but also from type 2 diabetes in adults.
titrated. B
13.70 If glycemic targets are no longer met with met-
Management
formin (with or without basal insulin), liraglutide
Treatment of youth-onset type 2 diabetes by a multi- (a GLP-1 receptor agonist) therapy should be
disciplinary team should include lifestyle management, considered in children 10 years of age or older if
diabetes self-management education, and pharmacologic they have no past medical history or family history
treatment. Current pharmacologic treatment options for

of medullary thyroid carcinoma or multiple en-
youth-onset type 2 diabetes are limited to three approved docrine neoplasia type 2. A
drugs: insulin, metformin, and liraglutide. 13.71 Patients treated with basal insulin who do not meet
Most youth with type 2 diabetes come from racial/ethnic glycemic target should be moved to MDI with basal
minority groups, have low socioeconomic status, and and premeal bolus insulins. E
often experience multiple psychosocial stressors. Con- 13.73 Use of medications not approved by the FDA for
sideration of the sociocultural context and efforts to youth with type 2 diabetes is not recommended
personalize diabetes management are of critical impor- outside of research trials. B
tance to minimize barriers to care, enhance adherence,
and maximize response to treatment. Transition From Pediatric to Adult Care
Recommendations
Glycemic Targets
Recommendations 13.110 Pediatric diabetes providers should begin to
prepare youth for transition to adult health care in
13.62 A reasonable A1C target for most children and
early adolescence and, at the latest, at least 1 year
adolescents with type 2 diabetes treated with
before the transition. E
oral agents alone is ,7% (53 mmol/mol).
13.111 Both pediatric and adult diabetes care providers
More stringent A1C targets (such as ,6.5%
should provide support and resources for tran-
[48 mmol/mol]) may be appropriate for selected
sitioning young adults. E
individual patients if they can be achieved without
13.112 Youth with type 2 diabetes should be transferred to
significant hypoglycemia or other adverse effects of
an adult-oriented diabetes specialist when deemed
treatment. Appropriate patients might include
appropriate by the patient and provider. E
those with short duration of diabetes and lesser
degrees of b-cell dysfunction and patients treated
with lifestyle or metformin only who achieve 14. MANAGEMENT OF DIABETES IN PREGNANCY
significant weight improvement. E
The prevalence of diabetes in pregnancy has been in-
13.63 Less stringent A1C goals (such as 7.5% [58
creasing in the U.S. in parallel with the worldwide epi-
mmol/mol]) may be appropriate if there is
demic of obesity. In general, specific risks of diabetes in
increased risk of hypoglycemia. E
pregnancy include spontaneous abortion, fetal anomalies,
preeclampsia, fetal demise, macrosomia, neonatal hy-
Pharmacologic Management poglycemia, hyperbilirubinemia, and neonatal respiratory
Recommendations distress syndrome, among others. In addition, diabetes in
13.65 Initiate pharmacologic therapy, in addition to be- pregnancy may increase the risk of obesity, hypertension,
havioral counseling for healthful nutrition and and type 2 diabetes in offspring later in life.
physical activity changes, at diagnosis of type 2
diabetes. A Preconception Counseling
13.66 In incidentally diagnosed or metabolically stable pa-
tients (A1C ,8.5% [69 mmol/mol] and asymptom- Recommendations
atic), metformin is the initial pharmacologic treatment 14.1 Starting at puberty and continuing in all women with
of choice if renal function is normal. A diabetes and reproductive potential, preconception

counseling should be incorporated into routine di- 14.15 Metformin, when used to treat polycystic ovary syn-
abetes care. A drome and induce ovulation, should be discontinued
14.2 Family planning should be discussed, and effective by the end of the first trimester. A
contraception (with consideration of long-acting,
reversible contraception) should be prescribed and Pregnancy and Drug Considerations
used until a woman’s treatment regimen and A1C are Recommendations
optimized for pregnancy. A
14.19 In pregnant patients with diabetes and chronic
14.3 Preconception counseling should address the im-
hypertension, a blood pressure target of 110–135/
portance of achieving glucose levels as close to
85 mmHg is suggested in the interest of reducing
normal as is safely possible, ideally A1C ,6.5% (48
the risk for accelerated maternal hypertension A
mmol/mol), to reduce the risk of congenital
and minimizing impaired fetal growth. E
anomalies, preeclampsia, macrosomia, preterm
14.20 Potentially harmful medications in pregnancy (i.e.,

birth, and other complications. B
ACE inhibitors, ARBs, statins) should be stopped at
conception and avoided in sexually active women
Preconception Care of childbearing age who are not using reliable
contraception. B
Recommendations
14.4 Women with preexisting diabetes who are Postpartum Care
planning a pregnancy should ideally be managed Recommendations
beginning in preconception in a multidisciplinary
14.21 Insulin resistance decreases dramatically imme-
clinic including an endocrinologist, maternal-fetal
medicine specialist, RD/RDN, and CDCES, when diately postpartum, and insulin requirements need
available. B to be evaluated and adjusted, as they are often
14.5 In addition to focused attention on achieving gly-
roughly half the pre-pregnancy requirements for
cemic targets A, standard preconception care should the initial few days postpartum. C
14.22 A contraceptive plan should be discussed and
be augmented with extra focus on nutrition, dia-
betes education, and screening for diabetes implemented with all women with diabetes of
comorbidities and complications. E reproductive potential. A
14.23 Screen women with a recent history of GDM at
14.6 Women with preexisting type 1 or type 2 diabetes who
are planning pregnancy or who have become pregnant 4–12 weeks postpartum, using the 75-g oral glu-
should be counseled on the risk of development and/or cose tolerance test and clinically appropriate
progression of diabetic retinopathy. Dilated eye ex- nonpregnancy diagnostic criteria. B
14.24 Women with a history of GDM found to have pre-
aminations should occur ideally before pregnancy or in
the first trimester, and then patients should be diabetes should receive intensive lifestyle interven-
monitored every trimester and for 1 year postpartum tions and/or metformin to prevent diabetes. A
14.25 Women with a history of GDM should have lifelong
as indicated by the degree of retinopathy and as
recommended by the eye care provider. B screening for the development of type 2 diabetes or
prediabetes every 1–3 years. B
14.26 Women with a history of GDM should seek pre-
Management of GDM conception screening for diabetes and precon-
ception care to identify and treat hyperglycemia
Recommendations
and prevent congenital malformations. E
14.13 Lifestyle behavior change is an essential component 14.27 Postpartum care should include psychosocial as-
of management of GDM and may suffice for the sessment and support for self-care. E
treatment of many women. Insulin should be added
if needed to achieve glycemic targets. A
14.14 Insulin is the preferred medication for treating
15. DIABETES CARE IN THE HOSPITAL
hyperglycemia in GDM. Metformin and glyburide Among hospitalized patients, hyperglycemia,
should not be used as first-line agents, as both cross hypoglycemia, and glucose variability are associated
the placenta to the fetus. A Other oral and non- with adverse outcomes, including death. Therefore,
insulin injectable glucose-lowering medications careful management of inpatients with diabetes has
lack long-term safety data. direct and immediate benefits. When caring for
hospitalized patients with diabetes, consult with a frequent bedside glucose testing, every 30 minutes to
specialized diabetes or glucose management team every 2 hours, is required for intravenous insulin infusion.
when possible.
Although CGM has theoretical advantages over point-of-
Hospital Care Delivery Standards care glucose testing in detecting and reducing the inci-
dence of hypoglycemia, it has not been approved by the
Recommendations
FDA for inpatient use. However, some hospitals with
15.1 Perform an A1C test on all patients with diabetes established glucose management teams allow the use of
or hyperglycemia (blood glucose .140 mg/dL CGM in selected patients.
[7.8 mmol/L]) admitted to the hospital if not
performed in the prior 3 months. B
15.2 Insulin should be administered using validated
Glucose-Lowering Treatment in

written or computerized protocols that allow for Hospitalized Patients
predefined adjustments in the insulin dosage based
on glycemic fluctuations. B
Recommendations
Considerations on Admission 15.6 Basal insulin or a basal plus bolus correction insulin
regimen is the preferred treatment for noncritically
Initial orders should state the type of diabetes, if known.
ill hospitalized patients with poor oral intake or
Because inpatient treatment and discharge planning are
those who are taking nothing by mouth. A
more effective if based on preadmission glycemia, an A1C
15.7 An insulin regimen with basal, prandial, and cor-
should be measured on all patients with diabetes or
rection components is the preferred treatment for
hyperglycemia if the test has not been performed in the
noncritically ill hospitalized patients with good
previous 3 months.
nutritional intake. A
15.8 Use of only a sliding-scale insulin regimen in the
Glycemic Targets in Hospitalized Patients inpatient hospital setting is strongly discouraged. A
Recommendations In certain circumstances, it may be appropriate to con-
15.4 Insulin therapy should be initiated for treatment tinue home regimens including oral glucose-lowering
of persistent hyperglycemia starting at a medications. If oral medications are held in the hospital,
threshold $180 mg/dL (10.0 mmol/L). Once insulin there should be a protocol for resuming them 1–2 days
therapy is started, a target glucose range of 140–180 before discharge.
mg/dL (7.8–10.0 mmol/L) is recommended for the
majority of critically ill and noncritically ill pa-
tients. A Insulin Therapy
15.5 More stringent goals, such as 110–140 mg/dL
In the critical care setting, continuous intravenous insulin
(6.1–7.8 mmol/L), may be appropriate for selected
infusion is the best method for achieving glycemic targets.
patients if they can be achieved without significant
Outside of critical care units, scheduled insulin regimens
hypoglycemia. C
as described above are recommended.
Hyperglycemia in hospitalized patients is defined as blood
glucose levels .140 mg/dL (7.8 mmol/L). Glucose levels For patients who are eating, insulin injections should align
persistently above this level should receive prompt with meals. In patients with unpredictable oral intake, a
conservative interventions to correct the hyperglycemia, safer procedure is to administer prandial insulin imme-
such as changes to diet or medications causing diately after the patient eats with the dose adjusted for the
hyperglycemia. amount ingested.
Hypoglycemia in the hospital is classified the same as in An insulin regimen with basal and correction components
any setting. (See “6. GLYCEMIC TARGETS.”) is necessary for all hospitalized patients with type 1 di-
abetes, with the addition of prandial insulin if patients are
Bedside Blood Glucose Monitoring eating. A transition protocol from insulin infusion to
In patients who are eating, bedside glucose monitoring subcutaneous insulin with the administration of basal
should be performed before meals; in those not eating, insulin 2 hours before discontinuing the intravenous
glucose monitoring is advised every 4–6 hours. More insulin drip is recommended.

Noninsulin Therapies Standards for Special Situations

The safety and efficacy of noninsulin glucose-lowering See “15. Diabetes Care in the Hospital” in the complete
therapies in the hospital setting is an area of active re- 2021 Standards of Care for guidance on enteral/
search. See “15. Diabetes Care in the Hospital” in the parenteral feedings, glucocorticoid therapy, perioperative
complete 2021 Standards of Care for a comprehensive care, and DKA and hyperosmolar hyperglycemic state.
review of the inpatient use of these medications.
Hypoglycemia Transition From the Acute Care Setting

Recommendations Recommendation
15.9 A hypoglycemia management protocol should be 15.11 There should be a structured discharge plan tailored
adopted and implemented by each hospital or to the individual patient with diabetes. B

hospital system. A plan for preventing and treating
hypoglycemia should be established for each pa- Medication Reconciliation
tient. Episodes of hypoglycemia in the hospital
• The patient’s medications must be cross-checked to
should be documented in the medical record and
ensure that no chronic medications were stopped and to
tracked. E
ensure the safety of new prescriptions.
15.10 The treatment regimen should be reviewed and
• Prescriptions for new or changed medication should be
changed as necessary to prevent further hypo-
filled and reviewed with the patient and family at or
glycemia when a blood glucose value of ,70 mg/dL
before discharge.
(3.9 mmol/L) is documented. C
Discharge planning should begin at admission and be
Patients with or without diabetes may experience
updated as patient needs change. An outpatient follow-up
hypoglycemia in the hospital setting. Insulin is one of the
visit 1 month after discharge is recommended. An earlier
most common drugs causing adverse events in hospi-
appointment (in 1–2 weeks) is preferred, and frequent
talized patients, and insulin dosing/administration errors
contact may be needed to avoid hyperglycemia and
occur relatively frequently.
hypoglycemia.
While hypoglycemia is associated with increased mor-
tality, it may be a marker of underlying disease rather than
the cause of fatality. Recently, several groups have de- Structured Discharge Communication
veloped algorithms to predict episodes of hypoglycemia
among inpatients. Models such as these are potentially • Information on medication changes, pending tests and
important and, once validated for general use, could studies, and follow-up needs must be accurately and
provide a valuable tool to reduce rates of hypoglycemia in promptly communicated to outpatient providers, in-
hospitalized patients. cluding transmission of the discharge summary to the
primary care provider as soon as possible after
discharge.
MNT in the Hospital
• Scheduling follow-up appointments prior to discharge
The goals of MNT in the hospital are to provide adequate increases the likelihood that patients will attend.
calories to meet metabolic demands, optimize glycemic
It is important that patients be provided with appropriate
control, address personal food preferences, and facilitate
durable medical equipment, medications, supplies, and
creation of a discharge plan. The ADA does not endorse
prescriptions along with education at the time of discharge.
any single meal plan.
Self-Management in the Hospital Preventing Admissions and Readmissions

Diabetes self-management in the hospital may be appro- Strategies aimed at reducing readmission include tar-
priate for specific patients. Sufficient cognitive and physical geted interventions for insulin treatment of patients with
skills, adequate oral intake, proficiency in carbohydrate admission A1C .9% (75 mmol/mol) and collaborative
estimation, and knowledge of sick-day management are patient-centered medical homes for people with DKD.
some of the requirements. Self-administered insulin with a
stable MDI regimen or insulin pump therapy may be Age is also an important risk factor in hospitalization and
considered. A protocol should exist for these situations. readmission among patients with diabetes.
16. DIABETES ADVOCACY Nashville, TN, Sandra Leal, PharmD, MPH, FAPhA, CDCES,
of Tucson, AZ, CDR Parmjeet Saini, DHSc, MPA, PA-C, of New
For a list of ADA advocacy position statements, including York, NY, Jay H. Shubrook, DO, of Vallejo, CA, and Jennifer
“Diabetes and Driving” and “Diabetes and Employment,” Trujillo, PharmD, FCCP, BCPS, CDCES, BC-ADM, of Aurora, CO,
see “16. Diabetes Advocacy” in the complete 2021 with ADA staff support from Sarah Bradley.
Standards of Care. The complete Standards of Medical Care in Diabetes—2021 was
developed by the ADA’s Professional Practice Committee: Boris
ACKNOWLEDGMENTS Draznin, MD, PhD (Chair), Vanita R. Aroda, MD, George Bakris,
This abridged version of the Standards of Medical Care in MD, Gretchen Benson, RDN, LD, CDCES, Florence M. Brown,
Diabetes—2021 was created by the ADA’s Primary Care MD, RaShaye Freeman, DNP, FNP-BC, CDCES, ADM-BC,
Advisory Group (PCAG), with special thanks to PCAG chair Jennifer Green, MD, Elbert Huang, MD, MPH, FACP, Diana
Eric L. Johnson, MD, of Grand Forks, ND, vice-chair Hope Isaacs, PharmD, BCPS, BC-ADM, CDCES, Scott Kahan, MD,
Feldman, CRNP, FNP-BC, of Philadelphia, PA, Amy Butts, PA-C, MPH, Christine G. Lee, MD, MS, Jose Leon, MD, MPH, Sarah K.
Lyons, MD, Anne L. Peters, MD, Jane E.B. Reusch, MD,

CDCES, BC-ADM, of Wheeling, WV, James Chamberlain, MD, of
Salt Lake City, UT, CDR Billy Collins, DHSc, PA-C, of Bethesda, and Deborah Young-Hyman, PhD, CDCES. ADA staff support
MD, Kacie Doyle-Delgado, DNP, NP-C, of Salt Lake City, UT, includes Mindy Saraco, MHA, Malaika I. Hill, MA, Matthew P.
Joy Dugan-Moverley, MPH, DHS(c), PA-C, of Vallejo, CA, Petersen, Shamera Robinson, MPH, RDN, Jo Mandelson, MS,
RaShaye Freeman, DNP, FNP-BC, CDCES, ADM-BC, of RDN, and Robert A. Gabbay, MD, PhD.

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STANDARDS OF CARE

Standards of Medical Care in Diabetes—2021 Abridged

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VOLUME 39, NUMBER 1, WINTER 2021 15

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Prevention of Vascular Disease and Mortality Recommendations

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5. FACILITATING BEHAVIOR CHANGE AND

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Psychosocial Issues Glycemic control is assessed by the A1C measurement,

recommended. B needed, in patients whose therapy has recently

Diabetes Distress Glucose Assessment by CGM

VOLUME 39, NUMBER 1, WINTER 2021 21

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A1C ,7.0% (53 mmol/mol)*# Recommendation

VOLUME 39, NUMBER 1, WINTER 2021 23

loss has been shown to improve glycemic control and

Intermittently scanned CGM systems that measure glucose levels

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VOLUME 39, NUMBER 1, WINTER 2021 25

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The Risk Calculator Pharmacologic Interventions

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Lifestyle Intervention Recommendations

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VOLUME 39, NUMBER 1, WINTER 2021 31

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FIGURE 11.1 Risk of CKD progression,

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12. OLDER ADULTS

Neurocognitive Function 12.8 Screening for diabetes complications should be

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Treatment in Skilled Nursing Facilities and

Type 2 Diabetes 13.67 Youth with marked hyperglycemia (blood glucose

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VOLUME 39, NUMBER 1, WINTER 2021 39

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Noninsulin Therapies Standards for Special Situations

Hypoglycemia Transition From the Acute Care Setting

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Self-Management in the Hospital Preventing Admissions and Readmissions