The American Diabetes Association® (ADA) Standards of Care 2024 Update

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The American Diabetes Association® (ADA) Standards of Care 2024 Update

Diabetes mellitus is a metabolic disorder characterized by elevated blood glucose levels. The primary subtypes are type 1 diabetes mellitus and type 2 diabetes mellitus, distinguished by defects in insulin secretion or action, respectively. Type 1 diabetes mellitus typically manifests in children or adolescents, while type 2 is associated with middle-aged and older adults due to prolonged hyperglycemia stemming from lifestyle factors.¹

The American Diabetes Association's (ADA) "Standards of Care in Diabetes" is a crucial resource providing guidelines for clinicians, researchers, and others involved in diabetes care. It outlines strategies for managing diabetes, emphasizing the importance of continuous medical attention and multifaceted risk reduction beyond simply managing blood sugar levels. It offers recommendations for individuals of all ages, including youth, adults, and older adults. The 2024 update of ADA guidelines signifies an advancement in diabetes care, ensuring that healthcare professionals have access to comprehensive, evidence-based strategies for managing the condition effectively.²

One of these key updates pertains to a new recommendation regarding pharmacologic interventions to delay the onset of symptomatic type 1 diabetes. Teplizumab-mzwv is now recommended for consideration in selected individuals aged 8 years and older with stage 2 type 1 diabetes (Level of Evidence [LOE] B). This recommendation is supported by clinical trials demonstrating the efficacy of teplizumab in delaying the onset of stage 3 type 1 diabetes. Specifically, a study involving relatives of people with type 1 diabetes showed that teplizumab treatment resulted in a significantly longer median time to diagnosis of stage 3 type 1 diabetes compared to placebo. In this study, 44 individuals were randomized to receive a 14-day course of teplizumab, while 32 received a placebo. The median time to stage 3 type 1 diabetes diagnosis was 48.4 months in the teplizumab group compared to 24.4 months in the placebo group. Type 1 diabetes was diagnosed in 19 (43%) of participants who received teplizumab and 23 (72%) of those who received placebo (hazard ratio [HR] 0.41; 95%; confidence interval [CI] 0.22 to 0.78), indicating a significant reduction in risk. Adverse reactions to teplizumab were generally mild and included transient lymphopenia and rash.^3,4

Updates have also been made regarding obesity and weight management for the prevention and treatment of type 2 Diabetes. Specifically, in individuals with diabetes who are overweight or obese, the preferred pharmacotherapy should be a glucagon-like peptide 1 receptor agonist (GLP-1 RA) such as semaglutide, or dual glucose-dependent insulinotropic polypeptide and glucagon-like peptide 1 receptor agonist (GIP/GLP-1 RA) with greater weight loss efficacy, such as tirzepatide (LOE A). Two phase 3 trials have demonstrated the potential effectiveness of tirzepatide for obesity management: the SURMOUNT-1 trial, which included individuals with obesity, and the SURMOUNT-2 trial, which focused on individuals with obesity and type 2 diabetes. Notably, the SURMOUNT-2 trial showed body weight loss of 9.6% and 11.6% more than placebo and A1C lowering of 1.55% and 1.57% more than placebo after 72 weeks of treatment with the 10 mg and 15 mg doses, respectively. Adverse effects were similar to those seen with the GLP-1 receptor agonist class. Overall, these findings provide strong evidence supporting the use of tirzepatide in obesity management for individuals with diabetes.^5-7

Another pharmacological approach update emphasizes the importance of addressing both individualized glycemic and weight goals in adults with type 2 diabetes without cardiovascular and/or kidney disease (LOE A). This recommendation underscores the need for pharmacologic agents to target both glycemic control and weight management in this population. Furthermore, in adults with type 2 diabetes and established or high risk of cardiovascular disease, heart failure, and/or chronic kidney disease, it is recommended that the treatment plan incorporates agents that reduce cardiovascular and kidney disease risk, such as sodium–glucose cotransporter 2 inhibitors (SGLT2) and/or GLP-1 RA (LOE A). This recommendation reflects the prioritization of glycemic management agents that provide comprehensive cardiovascular risk reduction, independent of A1C levels, and considers individual-specific factors. Additionally, the guidelines now advise the use of SGLT2 inhibitors for glycemic control in adults with type 2 diabetes who have heart failure, with reduced or preserved ejection fraction, to prevent heart failure hospitalizations (LOE A).⁸

Regarding cardiovascular disease and risk management, for individuals with diabetes and atherosclerotic cardiovascular disease (ASCVD) who are intolerant to statin therapy, the ADA now suggests considering PCSK9 inhibitor therapy with monoclonal antibody treatment (LOE A), bempedoic acid therapy (LOE A), or PCSK9 inhibitor therapy with inclisiran siRNA (LOE E) as alternative cholesterol-lowering therapies. These recommendations provide additional options for managing cholesterol levels in individuals with diabetes and established cardiovascular disease who cannot tolerate statins.⁹

Updates were also made in the management of diabetes in pregnancy, specifically addressing the treatment of hyperglycemia in gestational diabetes mellitus. The recommendation emphasizes that insulin is the preferred medication for managing hyperglycemia in GDM. It cautions against the use of metformin and glyburide, either individually or in combination, as first-line agents due to their ability to cross the placenta to the fetus (LOE A). Furthermore, the guidelines highlight that other oral and noninsulin injectable glucose-lowering medications lack long-term safety data in pregnancy (LOE E). This update aims to provide clarity on the preferred pharmacological approach for treating hyperglycemia in pregnancy, prioritizing the safety of both the mother and the fetus.¹⁰

Notably, updates were also made regarding recommended immunizations, specifically concerning the respiratory syncytial virus (RSV) vaccine in adults aged 60 years and older with chronic conditions such as diabetes. This recommendation was based on the Advisory Committee on Immunization Practices (ACIP) recommendation, which suggests that adults aged 60 years and older may receive a single dose of an RSV vaccine, utilizing shared clinical decision-making.¹¹

Overall, the Standards of Care in Diabetes 2024 guidelines provide new recommendations and updates, reflecting the evolving landscape of diabetes management. Staying up to date with these guidelines is crucial for healthcare professionals to ensure they deliver the most effective and evidence-based care to individuals with diabetes. By staying informed, practitioners can incorporate the latest strategies for prevention, diagnosis, and management, ultimately improving patient outcomes and quality of life. For further details and additional latest updates, healthcare providers can access the Standards of Care in Diabetes 2024 guidelines on the American Diabetes Association website, which serves as a comprehensive resource to enhance patient care.

  

Update Description	Recommendation	Level of Evidence (LOE)
Pharmacologic Interventions to Delay Symptomatic Type 1 Diabetes	3.15 Teplizumab-mzwv infusion to delay the onset of symptomatic type 1 diabetes (stage 3) should be considered in selected individuals aged ≥8 years with stage 2 type 1 diabetes. Management should be in a specialized setting with appropriately trained personnel.	B
Weight Management Pharmacotherapy in Type 2 Diabetes	8.17 In people with diabetes and overweight or obesity, the preferred pharmacotherapy should be a glucagon-like peptide 1 receptor agonist or dual glucose-dependent insulinotropic polypeptide and glucagon-like peptide 1 receptor agonist with greater weight loss efficacy (i.e., semaglutide or tirzepatide), especially considering their added weight-independent benefits (e.g., glycemic and cardiometabolic).	A
Pharmacologic Approaches to Glycemic Treatment	9.18 In adults with type 2 diabetes and established or high risk of atherosclerotic cardiovascular disease, heart failure (HF), and/or chronic kidney disease (CKD), the treatment plan should include agent(s) that reduce cardiovascular and kidney disease risk (e.g., sodium–glucose cotransporter 2 inhibitor [SGLT2] and/or glucagon-like peptide 1 receptor agonist [GLP-1 RA])	A
Pharmacologic Approaches to Glycemic Treatment	9.19 In adults with type 2 diabetes who have heart failure (with either reduced or preserved ejection fraction), an SGLT2 inhibitor is recommended, for glycemic management and prevention of heart failure hospitalizations	A
Cardiovascular Disease Risk Management	10.28b For people with diabetes and ASCVD intolerant to statin therapy bempedoic acid therapy should be considered as an alternative cholesterol-lowering therapy.	A
	10.28b For people with diabetes and ASCVD intolerant to statin therapy, PCSK9 inhibitor therapy with monoclonal antibody treatment should be considered as an alternative cholesterol-lowering therapy.	A
	10.28b For people with diabetes and ASCVD intolerant to statin therapy PCSK9 inhibitor therapy with inclisiran siRNA E should be considered as an alternative cholesterol-lowering therapy.	E
Management of Gestational Diabetes Mellitus	15.15 Insulin is the preferred medication for treating hyperglycemia in GDM. Metformin and glyburide, individually or in combination, should not be used as first-line agents, as both cross the placenta to the fetus.	A
	15.15 Other oral and noninsulin injectable glucose-lowering medications lack long-term safety data.	E
RSV vaccine for adults ≥60 with chronic conditions (e.g., diabetes)*	Consider RSV vaccine for adults ≥60 with chronic conditions like diabetes, with shared clinical decision-making.	--
*Recommendation from the Advisory Committee on Immunization Practices For the full updates and recommendations, please visit https://diabetesjournals.org

References

1. Sapra A, Bhandari P. Diabetes. In: StatPearls. Treasure Island (FL): StatPearls Publishing; June 21, 2023.
2. American Diabetes Association Professional Practice Committee, ElSayed NA, Aleppo G, et al. Introduction and methodology: standards of care in diabetes—2024. Diabetes Care. 2024;47(Supplement_1):S1-S4.
3. American Diabetes Association Professional Practice Committee. 3. Prevention or Delay of Diabetes and Associated Comorbidities: Standards of Care in Diabetes-2024. Diabetes Care. 2024;47(Suppl 1):S43-S51. doi:10.2337/dc24-S003
4. Herold KC, Bundy BN, Long SA, et al.; Type 1 Diabetes TrialNet Study Group. An anti-CD3 antibody, teplizumab, in relatives at risk for type 1 diabetes. N Engl J Med 2019;381:603–613
5. American Diabetes Association Professional Practice Committee. 9. Pharmacologic Approaches to Glycemic Treatment: Standards of Care in Diabetes-2024. Diabetes Care. 2024;47(Suppl 1):S158-S178. doi:10.2337/dc24-S009
6. Jastreboff AM, Aronne LJ, Ahmad NN, et al. Tirzepatide Once Weekly for the Treatment of Obesity. N Engl J Med. 2022;387(3):205-216. doi:10.1056/NEJMoa2206038
7. Garvey WT, Frias JP, Jastreboff AM, et al. Tirzepatide once weekly for the treatment of obesity in people with type 2 diabetes (SURMOUNT-2): a double-blind, randomised, multicentre, placebo-controlled, phase 3 trial. Lancet. 2023;402(10402):613-626. doi:10.1016/S0140-6736(23)01200-X
8. American Diabetes Association Professional Practice Committee. 10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes-2024. Diabetes Care. 2024;47(Suppl 1):S179-S218. doi:10.2337/dc24-S010
9. American Diabetes Association Professional Practice Committee. 15. Management of Diabetes in Pregnancy: Standards of Care in Diabetes-2024. Diabetes Care. 2024;47(Suppl 1):S282-S294. doi:10.2337/dc24-S015
10. American Diabetes Association Professional Practice Committee. 4. Comprehensive Medical Evaluation and Assessment of Comorbidities: Standards of Care in Diabetes-2024. Diabetes Care. 2024;47(Suppl 1):S52-S76. doi:10.2337/dc24-S004
11. The Centers for Disease Control and Prevention (CDC). Respiratory Syncytial Virus (RSV) Advisory Committee on Immunization Practices (ACIP) Vaccine Recommendations. Updated December 12, 2023. Accessed March 20, 2024.

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