Overview of the American Diabetes Association’s 2024 Standards of Care

RELEASE DATE

November 1, 2024

EXPIRATION DATE

November 30, 2026

FACULTY

Yvette C. Terrie, BS Pharm, RPh
Clinical Pharmacist/Freelance Medical Writer
Haymarket, Virginia

FACULTY DISCLOSURE STATEMENTS

Dr. Terrie has no actual or potential conflicts of interest in relation to this activity.

Postgraduate Healthcare Education, LLC does not view the existence of relationships as an implication of bias or that the value of the material is decreased. The content of the activity was planned to be balanced, objective, and scientifically rigorous. Occasionally, authors may express opinions that represent their own viewpoint. Conclusions drawn by participants should be derived from objective analysis of scientific data.

ACCREDITATION STATEMENT

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Credits: 2.0 hours (0.20 ceu)
Type of Activity: Knowledge

TARGET AUDIENCE

This accredited activity is targeted to pharmacists. Estimated time to complete this activity is 120 minutes.

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DISCLAIMER

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patients’ conditions and possible contraindications or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

GOAL

To familiarize pharmacists with current American Diabetes Association (ADA) recommendations for managing and preventing diabetes.

OBJECTIVES

After completing this activity, the participant should be able to:

  1. Describe the incidence, prevalence, risk factors, and complications of diabetes.
  2. Discuss the 2024 ADA Standards of Care guidelines for diagnosing, classifying, preventing, and treating diabetes and prediabetes.
  3. Explain the pharmacist’s role in diabetes management.
  4. Restate evidence-based data demonstrating the beneficial effects of pharmacist involvement in diabetes care, patient-centered treatment plans, and patient education.

ABSTRACT: The incidence and prevalence of diabetes and prediabetes are continuing to climb in the United States, resulting in numerous health and economic burdens, especially if left undetected and uncontrolled. Early diagnosis, clinical intervention, and patient adherence are crucial for effective diabetes management, which also involves pharmacologic and nonpharmacologic treatments tailored to the patient’s needs. Updates to the American Diabetes Association’s 2024 Standards of Care guidelines include new recommendations to achieve improved quality of care and better clinical outcomes. Pharmacists play a key role in diabetes care, and the updated guidelines are designed to help them implement effective patient-centered treatment plans, which can potentially improve outcomes and prevent or reduce diabetes-related complications, thereby enhancing overall health-related quality of life.

Diabetes is a chronic, progressive disease that requires continual monitoring and treatment to maintain glycemic control, and its incidence and prevalence continue to soar despite advances in recognition and treatment.1,2 The most recent statistics from the CDC and the American Diabetes Association (ADA) reveal that an estimated 38.4 million people in the United States have diabetes, representing 11.6% of the population. Of this number, it is estimated that 29.7 million people have been diagnosed (29.4 million of them adults), with 8.7 million persons remaining undiagnosed (equivalent to 22.8% of adults with diabetes).1,2 Moreover, in the U.S., a total of 97.6 million people aged 18 years or older have prediabetes, representing 38.0% of the adult population, and 27.2 million of those aged 65 years or older (48.8%) have prediabetes.1,2 Early recognition and clinical intervention, as well as implementation of effective patient-education initiatives, are crucial to preventing or reducing the numerous risks associated with uncontrolled diabetes, especially since the most recent ADA statistics indicate that diabetes was the 8th leading cause of death in the U.S. in 2021.2 The ongoing overweight and obesity epidemic in the U.S. and worldwide has contributed to the increased incidence and prevalence of diabetes, with an estimated 1.2 million new cases of diabetes diagnosed annually in the U.S.2,3

Compared with those without diabetes, patients with diabetes have a twofold to fourfold greater risk of cardiovascular (CV) disease, including myocardial infarction, stroke, and peripheral vascular disease, and the risk increases with lack of glycemic control.3-5 Additionally, CV disease is often the principal cause of mortality in patients with type 2 diabetes (T2D). Diabetes-related complications—which are classified as macrovascular (coronary heart disease, cerebrovascular disease, heart failure, peripheral vascular disease, chronic kidney disease) and microvascular (diabetic retinopathy, diabetic neuropathy, diabetic nephropathy)—contribute to a substantial reduction in health-related quality of life, disability, and premature mortality in this patient population.3-5

The ADA notes that continued diabetes self-management education and clinician support play a crucial part in empowering patients with diabetes to prevent and reduce acute complications related to diabetes and diminishing the risk of long-term diabetes-related complications.2 Additionally, abundant evidence-based clinical data support numerous pharmacologic and nonpharmacologic interventions tailored to patient needs, which can enhance clinical outcomes in diabetes.

Ongoing research efforts have led to increased insight into the complex, multifaceted, progressive pathogenesis of diabetes; research also has highlighted the significance of early recognition and clinical intervention in preventing and reducing the incidence and prevalence of diabetes and its numerous related complications, which—if left undetected and untreated—eventually affect every organ system in the body. Advances in technology and additions to the treatment landscape, including the approval of new drug classes that are formulated to target the underlying pathophysiologies associated with diabetes, provide clinicians with valuable tools to effectively manage and treat diabetes.

THE IMPORTANCE OF PATIENT-CENTERED TREATMENT PLANS

The rising incidence and prevalence of T2D and the numerous health and economic challenges associated with undiagnosed and uncontrolled cases necessitate effective strategies for identifying and addressing barriers to care. A key approach to practical management entails measures to slow disease progression and prevent or reduce diabetes-related complications.6 Implementation of these measures can lead to optimal clinical outcomes for patients diagnosed with diabetes and prediabetes. Evidence-based guidelines emphasize that implementation of a healthy lifestyle (e.g., diet and exercise) in conjunction with medications as needed can effectively delay the progression of T2D and avert or diminish the occurrence of diabetes-related complications.6,7

T2D is frequently referred to as a self-managed condition because the involvement of the patient is essential to improving glycemic control and managing the disease.6,7 A 2020 consensus report developed by the ADA, Association of Diabetes Care & Education Specialists, the Academy of Nutrition and Dietetics, American Academy of Family Physicians, American Academy of PAs, American Association of Nurse Practitioners, and American Pharmacists Association provided guidelines and recommendations to guide clinicians in educating patients about the importance of diabetes self-management education and support (DSMES) in improving clinical outcomes.7 The overarching goal of the consensus report was to encourage clinicians to act as a patient educator and advocate to help patients understand their critical role in managing their diabetes.7

Recommended patient-centered strategies for the treatment and management of diabetes are presented in TABLE 1.8-10

SUMMARY OF THE ADA STANDARDS OF CARE GUIDELINE UPDATES

The ADA’s most recent diabetes care guidelines, Standards of Care in Diabetes—2024 (referred to hereafter as "2024 Standards of Care"), emphasize the role of patient-centered care and its profound impact on improving clinical outcomes. Since 1989, the ADA has published expert-recommended guidelines for diagnosing, treating, and managing diabetes based on an extensive review of the latest clinical data on diabetes.11-13 The guidelines are updated annually by the ADA’s Professional Practice Committee (PPC), which comprises 21 global experts from various professional fields, including physicians, nurse practitioners, certified diabetes care and education specialists, pharmacists, registered dietitians, and methodologists.13 Members of the PPC are experienced in areas such as adult and pediatric endocrinology, diabetes prevention, diabetes-management technology, CV risk management, renal disease, microvascular complications, preconception and pregnancy care, weight management, behavioral and mental health, inpatient care, epidemiology, and public health. In updating the guidelines, the PPC also consults with a team of 19 specialized content experts.13

The 2024 Standards of Care accentuate the importance of patient-centered and inclusive language, and the guideline updates consistently employ terminology that encourages the use of shared decision-making strategies, which have the potential to motivate patients to become active participants in their care so that they can effectively manage and treat diabetes while also preventing or lessening diabetes-related complications.11-13 The 2024 Standards of Care incorporate the ADA’s latest clinical practice recommendations, which outline the critical components of diabetes care, establish general treatment goals and guidelines, and offer clinicians effective strategies for optimal diagnosis and treatment of diabetes.

The updates incorporated into the 2024 Standards of Care provide clinicians with comprehensive, evidence-based guidelines based on data from current scientific research and clinical trials on effective treatment and management of type 1 diabetes (T1D), T2D, gestational diabetes, and prediabetes.11-13 The updated guidelines and recommendations include effective methods for the diagnosis and treatment of diabetes in both pediatric and adult patients; clinical approaches that may slow the progression of T2D and its associated comorbidities; and recommendations for therapeutic interventions to prevent or lessen diabetes-related complications and other related chronic comorbidities, such as CV disease, and enhance overall health outcomes.11-13

The 2024 Standards of Care include revisions and updates to nearly all sections (TABLE 2). Among the updates are detailed recommendations for specific patient populations with diabetes, including older adults, children and adolescents, and pregnant women.11-13 The following discussion summarizes some of the revisions and updates the ADA made to each section of the 2024 Standards of Care. (Note: Some of the section titles have been paraphrased here for brevity.)

Section 1: Enhancing Diabetes Care and Supporting Population Health

The ADA states that clinicians should employ a comprehensive strategy that includes interventions tailored to three elements—patient level, system level, and policy level—that are critical for improving population health in the context of diabetes. Population health is described as "the health outcomes of a group of individuals, including the distribution of health outcomes within the group."12,14 These outcomes can be measured with respect to terms of health outcomes (mortality, morbidity, and functional status), disease burden (incidence and prevalence), and behavioral and metabolic factors (e.g., physical activity, nutrition, A1C). The key elements that can potentially improve diabetes care and population health are delineated in FIGURE 1.14

The ADA notes that clinical practice recommendations for healthcare professionals are tools that can eventually enhance health across populations; however, for optimal outcomes, diabetes care must also be patient-centered and continue across the lifespan.14 Recommendation 1.1 states that clinicians should implement prompt treatment decisions based on evidence-based guidelines and consider critical social determinants of health. Clinicians should work collaboratively with patients and their care partners, considering their preferences, prognosis, comorbidities, and financial situation. As discussed in recommendation 1.2, diabetes-management strategies should align with the chronic care model, which focuses on patient-centered care, integrated long-term treatment for diabetes and comorbidities, and continuous, collaborative goal-setting and communication among all team members.14 Recommendation 1.3 stresses that care systems should support both in-person and virtual team-based care; include team members with expertise in diabetes management; and employ patient registries, decision-support tools, and community involvement to address the needs of patients with diabetes.14 Recommendation 1.4 states that diabetes healthcare maintenance should be evaluated using reliable and relevant data metrics to improve care processes and health outcomes, with consideration of care costs, the individual patient’s preferences and goals, and the treatment burden.14

Section 2: Diagnosing and Classifying Diabetes

This section provides updated guidance for diagnosing and classifying diabetes. The ADA modified the title of this section to accurately depict real-world clinical practice (i.e., diagnosis occurs before classification), with key additions described below.

Recommendation 2.1a emphasizes the need for a systematic approach to diagnostic testing, and recommendation 2.1b underscores the significance of confirmatory testing when an abnormal result is detected. Updated tables now rank A1C at the top of the testing ladder for diagnosing diabetes and prediabetes.15

Recommendation 2.5 accentuates the importance of distinguishing between the different types of diabetes when implementing patient-centered management plans. Categories of diabetes include T1D, T2D, gestational diabetes, and specific other types of diabetes due to specific causes (e.g., monogenic diabetes syndromes such as neonatal diabetes and maturity-onset diabetes of the young; diseases of the exocrine pancreas such as cystic fibrosis and pancreatitis; and drug or chemical-induced diabetes such as with glucocorticoid use, in HIV treatment, or after organ transplantation).15

Section 2 has added a structured outline for assessing for suspected T1D in newly diagnosed adults in whom the diabetes type was unclear at time of diagnosis. The T1D subsection has refined diagnostic criteria based on the recent FDA approval of teplizumab, a new monoclonal antibody injection, which is indicated to delay the onset of stage 3 T1D in patients aged 8 years and older who have stage 2 T1D.15 Recommendation 2.8 was added to include the consideration of standardized islet autoantibody tests for classification. Based on clinical data, new information highlights the possible association between COVID-19 and new-onset T1D.15

Recommendation 2.15a enumerates the pharmacologic classes (e.g., glucocorticoids, statins, thiazide diuretics, second-generation antipsychotics) that could heighten the risk of prediabetes and T2D and includes a screening protocol.15 Recommendation 2.15b provides monitoring recommendations for pre-diabetes and T2D in patients treated with second-generation antipsychotics.15

Recommendation 2.17 emphasizes preferred screening of patients for diabetes after an acute pancreatitis episode; screening is also recommended in patients with chronic pancreatitis. Recommendation 2.18 presents guidance on cystic fibrosis-related diabetes (CFRD). Recommendation 2.19 was modified to clarify the use of A1C testing in CFRD diagnosis.15

Section 3: Preventing or Delaying Diabetes and Related Comorbidities

Updates to this section include clinical practice recommendations for preventing or delaying diabetes and associated comorbidities by routinely monitoring patients with prediabetes and at risk for diabetes; assessing risk factors; and ordering A1C and glucose tolerance tests. Also included are recommendations for instituting lifestyle interventions, including patient-centered nutritional plans and exercise regimens, which are effective for preventing and delaying the development of T2D and for managing cardiometabolic risk factors including hypertension, hyperlipidemia, and inflammation.16

Recommendation 3.2 focuses on the monitoring of patients who are at risk for T1D. Key factors to consider include younger age of seroconversion, particularly younger than age 3 years; the number of diabetes-related autoantibodies identified; and the development of autoantibodies against islet antigen 2.16 Recommendation 3.15 notes that teplizumab is approved for use in delaying the onset of stage 3 T1D and may be prescribed in patients aged 8 years and older with stage 2 T1D.16

Section 4: Medical Assessment and Comorbidity Evaluation

This section focuses on optimizing health outcomes and health-related quality of life by employing an individualized communication style. The Immunizations subsection now includes postpandemic COVID-19 information and respiratory syncytial virus vaccine recommendations for diabetic patients aged 60 years and older.17 The Bone Health subsection was extensively revised to include new fracture risk factors and is endorsed by the American Society for Bone and Mineral Research.13,17

Aspects fostering a patient-centered communication style, such as language and active listening, are discussed in detail in recommendation 4.1. The ADA notes that this method should be employed to optimize health outcomes and health-related quality of life.17 In recommendation 4.22, evaluation and referral processes were added for patients needing assistance with disability management, and alterations to the 2023 Living Standards update include extensive recommendations for screening and managing liver disease and nomenclature changes for steatotic liver disease.17

Section 5: Enabling Positive Health Behaviors and Well-Being

The recommendations in Section 5 were modified to address the behavior of the healthcare professional rather than that of the patient, aligning with the ADA Standards of Care’s purpose of providing professional guidance.18 One of the key modifications and additions to this section is recommendation 5.1, which advises clinicians to encourage patients with diabetes to practice DSMES to aid in making decisions about care and work actively with their healthcare professional. Recommendation 5.2 discusses crucial times to assess the need for diabetes education, including at diagnosis; when glycemic targets and goals are not achieved; when medical, physical, or psychosocial challenges arise; and when changes in life and care arise. Recommendation 5.3 emphasizes that critical goals of DSMES, including clinical outcomes, health status, and overall well-being, should be routinely evaluated as part of diabetes care.18

Recommendation 5.4 suggests that DSMES be tailored to patients’ needs and values while considering their culture and preferences; it also notes that education and support should be part of a patient’s medical record and made available to the multidisciplinary care team. Recommendation 5.5 encourages offering DSMES through telehealth and other digital technologies to address barriers to care and enhance patient satisfaction. Recommendation 5.13 was added to the Medical Nutrition Therapy subsection to include general diet guidance for patients with diabetes, and recommendation 5.20 was updated to emphasize the inclusion of healthy fats associated with Mediterranean-style diets. Recommendation 5.31 was revised to define sedentary behavior and the clinical benefits of high-intensity interval exercises. Additionally, the Smoking Cessation: Tobacco, E-Cigarettes, and Cannabis subsection was updated to include a discussion on cannabis use.18 Recommendation 5.36 was updated to include a discussion of integrating psychosocial screenings into diabetes care. Recommendation 5.40 was revised to include information for screening patients for fear of hypoglycemia, and recommendation 5.51 was added to encourage sleep hygiene and sleep-promoting routines and habits.18

Section 6: Glycemic Goals and Hypoglycemia

Section 6 has been retitled Glycemic Goals and Hypoglycemia, as reflected here, and hypoglycemia content from throughout the Standards of Care has been merged into this section.19 Recommendation 6.1 was updated to address the needs of patients who require closer monitoring of glycemic levels, suggesting more frequent evaluation of these levels. Recent clinical data discussed the strengths and limitations of A1C and other glycated proteins, leading to updated continuous glucose monitor (CGM) metrics and glycemic goals. Recommendations 6.8a and 6.8b discuss the deintensification of diabetes medications. Recommendations 6.11a, 6.11b, and 6.11c offer guidance on assessing hypoglycemia awareness and risk, and recommendation 6.11d highlights the benefits of CGM use for hypoglycemia prevention. Hypoglycemia treatment guidance for patients using automated insulin delivery (AID) systems is included in recommendation 6.12. Recommendation 6.13 clarifies glucagon prescribing criteria, favoring nonreconstituted preparations. Recommendation 6.14 emphasizes patient education on hypoglycemia prevention and treatment, especially for insulin users. Recommendations 6.15 and 6.16 guide how hypoglycemic events should inform diabetes treatment plans and promote interventions to reestablish hypoglycemia awareness.19

Section 7: Diabetes Technology

To expand awareness about the clinical benefits associated with diabetes technology and to encourage clinicians to offer these technologies to patients who would benefit from them, this section contains updates such as recommendation 7.1, which added the option to suggest any diabetes device to patients, and recommendation 7.2, which emphasizes the value of initiating CGM use early in T1D, even at diagnosis.20 Recommendation 7.3 accentuates the need for healthcare professionals to have sufficient knowledge and competency in diabetes technology, and recommendation 7.8 supports the early initiation of insulin pumps and/or AID systems for T1D, including at diagnosis. Recommendation 7.15 reflects the benefits of intermittently scanned CGM in less intensively treated T2D. Recommendation 7.24 highlights the helpfulness of insulin pens or insulin injection aids for patients with dexterity issues or vision impairment, and recommendation 7.33 advises the continuation of personal CGM use in hospitalized patients when clinically suitable.20

Section 8: Obesity and Weight Management for Preventing and Treating T2D

This section, which is endorsed by the Obesity Society, offers evidence-based recommendations for managing overweight and obesity in T2D patients, highlighting the benefits of weight loss for improving clinical outcomes.13,21 Recommendations 8.2a, 8.2b, and 8.3 have incorporated additional anthropometric measurements beyond BMI, such as waist circumference and waist-to-hip ratio.21 Personalized approaches to treating obesity, including behavioral, pharmacologic, and surgical interventions, are featured in recommendation 8.6. Recommendation 8.8b has been updated to suggest counseling approaches to address barriers to access. Recommendations 8.11a and 8.11b emphasize the efficacy of weight-maintenance programs and suggest monitoring weight-loss progress. Recommendation 8.17 includes glucagon-like peptide 1 (GLP-1) receptor agonists or dual glucose-dependent insulinotropic polypeptide (GIP) and GLP-1 receptor agonists as preferred pharmacotherapy for obesity management in patients with diabetes. Recommendation 8.18 addresses the importance of reevaluation for obesity treatment intensification or deintensification. Recommendation 8.19 reflects the clinical evidence demonstrating the long-term benefits of metabolic surgery. Recommendation 8.20 now includes information about accredited metabolic and bariatric surgery centers, and recommendation 8.25 advises monitoring weight-loss progress post metabolic surgery.21

Section 9: Pharmacologic Approaches to Glycemic Treatment

This section offers evidence-based recommendations for managing glycemic control in patients with T1D or T2D, with consideration of patient factors such as comorbidities and overall goals.22

For T1D, the 2024 Standards of Care guidelines have been updated to include several key recommendations. Recommendation 9.2 expresses a preference for insulin analogues or inhaled insulin to reduce the risk of hypoglycemia in most adults with T1D. Recommendation 9.3 suggests early CGM use for better glucose control, and recommendation 9.4 discusses the consideration of AID systems for adults with T1D.22 Recommendation 9.5 highlights the importance of patient education regarding how to adjust insulin doses based on glycemia, glycemic trends, and sick-day management. Recommendation 9.6 recommends that glucagon be prescribed for patients at increased risk of hypoglycemia, and recommendation 9.7 stresses the need to regularly evaluate the treatment plan to ensure achievement of individualized glycemic goals.22

Regarding T2D, recommendation 9.14 highlights the utility of early combination therapy in attaining treatment goals, and recommendation 9.15 was added to address suggested pharmacologic therapies based on individual glycemic and weight goals.22 Recommendation 9.16 was included to provide additional advice for prescribing other diabetes therapies in patients not meeting glycemic targets, and recommendation 9.17 was added to discuss the implementation of treatment intensification and/or combination therapy to achieve weight loss and glycemic targets. Recommendation 9.18 now includes therapies that may also reduce the risk of CV and renal disease in adults with T2D who have or are at elevated risk for CV disease, heart failure, and/or chronic kidney disease (CKD). Recommendation 9.19 has been revised to discuss glycemia management and prevention of heart failure and hospitalizations in T2D patients with use of sodium-glucose cotransporter 2 (SGLT2) inhibitors. Recommendations 9.20 and 9.21 now provide patient-centered guidelines for treating CKD in patients with T2D. Recommendation 9.22 has been revised to include guidance on initiating insulin therapy at any stage under certain circumstances, and recommendation 9.23 suggests dual GIP and GLP-1 receptor agonists as preferred additional options over insulin for better blood glucose management.22

Recommendation 9.24 emphasizes the need to reevaluate insulin dosing after the addition or dose increase of GLP-1 receptor agonists or dual GIP and GLP-1 receptor agonists, and recommendation 9.25 has been expanded to include additional glucose-lowering agents, if needed, to meet treatment goals such as weight management, cardiometabolic benefits, or renal benefits.22 Recommendation 9.26 advises reevaluating indications for use or dosages of diabetes medications associated with a higher incidence of hypoglycemia, particularly when initiating or intensifying insulin therapy.22

Section 10: CV Disease and and Risk Management

This section offers evidence-based recommendations for preventing and treating CV and renal diseases in patients with diabetes, tailored to their risk factors and health status. It has been endorsed by the American College of Cardiology.23

Recommendation 10.12 advises the monitoring of serum creatinine/estimated glomerular filtration rate and potassium within 7 to 14 days after initiating an ACE inhibitor, angiotensin receptor blocker, mineralocorticoid receptor agonist, or diuretic.23 Recommendation 10.24 introduces bempedoic acid for patients who are intolerant to statin therapy, and recommendation 10.28b adds bempedoic acid and proprotein convertase subtilisin/kexin type 9 inhibitors as alternative cholesterol-lowering therapies; a new subsection titled Intolerance to Statin Therapy expands on these updates. Recommendation 10.35b suggests an interprofessional team approach for deciding the duration of dual antiplatelet therapy. Recommendations 10.39a and 10.39b include using natriuretic peptide levels to screen for asymptomatic heart failure. Recommendation 10.40 discusses screening for peripheral arterial disease with anklebrachial index testing in certain diabetic populations (patients aged 50 years and older; those with microvascular disease in any location, foot complications, or any end-organ damage due to diabetes) and suggests that peripheral arterial disease screening be considered in diabetic patients aged 10 years and older. Recommendation 10.42a advises SGLT2 or SGLT1/2 inhibitors for heart failure management. Recommendations 10.45a through 10.45e address treatment approaches for heart failure, including interprofessional team involvement and pharmacologic strategies, and recommendation 10.47 suggests educating selected patients on ketoacidosis risks and signs, management methods, and testing tools.23

Section 11: CKD and Risk Management

This section includes updated evidence-based guideline recommendations for diabetes management in patients with CKD based on ADA and Kidney Disease: Improving Global Outcomes data. Recommendation 11.4a highlights the role of ACE inhibitors and angiotensin receptor blockers in preventing renal disease progression and reducing CV events, and recommendation 11.7 has been revised to reflect dietary protein intake levels for patients with stage 3 or higher CKD who are currently on dialysis.24

Section 12: Retinopathy, Neuropathy, and Foot Care

This section gives updated recommendations regarding the prevention and management of retinopathy and neuropathy in patients with diabetes as well as new information on foot care. Recommendations 12.15 and 12.16 address vision loss from diabetes, with expanded information on complications and the importance of evaluation and rehabilitation.25 Recommendation 12.27 has been revised to include toe pressure assessment when screening for peripheral arterial disease, and recommendation 12.28 has been amended to emphasize an interprofessional approach, including a podiatrist, for patients who have foot ulcers or high-risk feet.25

Section 13: Older Adults

This section offers evidence-based recommendations for older patients based on their unique medical, physical, psychological, and social needs.26 Recommendation 13.6 aligns with updated Medicare rules allowing CGM for adults with T2D on any insulin. Recommendations 13.8a, 13.8b, and 13.8c emphasize personalized glycemic goals for older adults with intermediate or complex health conditions. Recommendations 13.16a through 13.16d focus on deintensifying therapy, especially medications that can cause hypoglycemia, and suggest switching to lower-risk medications and those that decrease cardiorenal risk in older adults with comorbidities.26

Section 14: Children and Adolescents

This section includes recommendations for managing diabetes in pediatric patients that address the specific needs of this population.27 Recommendation 14.4 discusses the importance of education regarding the need for insulin dosing adjustments according to meal composition. Recommendation 14.10 includes screening details for psychosocial and behavioral health concerns, and recommendation 14.12 discusses diabetes distress and lower engagement in self-management. Recommendation 14.53 has been revised to suggest at least a 7% to 10% decrease in excess weight for youth with T2D who are overweight or obese. Recommendations 14.68 and 14.70 now include the suggestion of employing empagliflozin before initiating or intensifying insulin therapy, when appropriate.

Recommendation 14.69 advises considering medication-taking behavior and weight effects for youth with T2D who are overweight or obese.27 Recommendation 14.72 has changed the term "severe obesity" to "class 2 obesity or higher," with specific BMI criteria. Recommendation 14.78 has been updated to refine protein intake according to age in patients with nephropathy. Newly added recommendations 14.106 and 14.107 advise discouraging smoking initiation and encouraging cessation, with expanded information on adverse health effects. Recommendations 14.108 and 14.109 highlight the role of the interprofessional team as patients transition from pediatric to adult care and recommend that these teams take a patient-centered approach. Finally, recommendation 14.110 has been added to guide coordination between pediatric and adult care specialists.27

Section 15: Managing Diabetes in Pregnancy

In this section, recommendation 15.4 has been amended to highlight the importance of interprofessional care, including a healthcare professional experienced in endocrinology.28 Recommendation 15.7 emphasizes that fasting, preprandial, and postprandial blood glucose levels be monitored in all pregnant women with diabetes. Recommendation 15.10 has been updated to include the use of CGM in patients with T1D.28

Section 16: Diabetes Care in the Hospital

This section provides evidence-based recommendations regarding diabetes management in hospitalized patients. Recommendation 16.2 advises that a personalized approach be used in various hospital settings and encourages regular audits and staff training. Recommendation 16.4 suggests initiating or intensifying insulin and other therapies for persistent hyperglycemia at a threshold of 180 mg/dL (10.0 mmol/L). Recommendation 16.5a sets glycemic goals for most critically ill patients at 140 mg/dL to 180 mg/dL, whereas recommendation 16.5b suggests stricter goals (110 mg/dL to 140 mg/dL) for selected critically ill patients, if attainable without substantial hypoglycemia.29 The Perioperative Care subsection includes a statement about the safe use of GLP-1 receptor agonists in the perioperative period, which ensures safe administration of these medications surrounding surgery and addresses potential concerns. The Glucose-Lowering Treatment in Hospitalized Patients subsection discusses coadministration of a low dose of basal insulin analogue while the patient is on IV insulin infusion, and recommendation 16.11 suggests prescribing an SGLT2 inhibitor in T2D patients who are hospitalized with heart failure and continuing it after recovery if no contraindications are present.29

Section 17: Diabetes Advocacy

This section summarizes the ADA’s updated advocacy statement on the care of young children with diabetes in childcare and community settings. This statement emphasizes the significance of developing and implementing proactive diabetes care plans for patients aged younger than 5 years and notes that this involves collaboration between healthcare providers, parents or guardians, and childcare staff.30

PHARMACIST INVOLVEMENT IN DIABETES CARE

Various publications have described the role of pharmacists in patients’ diabetes care, including educating patients about the disease, conducting comprehensive medication reviews, encouraging medication adherence, and discussing preventive care. As front-line healthcare professionals, pharmacists are ideally positioned to serve as educators and advocates for diabetic patients and their families or caregivers. Pharmacists’ medication expertise makes them an invaluable part of the multidisciplinary diabetes-management team. It has been shown that pharmacist involvement significantly enhances medication therapy outcomes and minimizes medication errors. Among the pharmacist’s responsibilities are screening patients for potential contraindications and drug interactions; addressing polypharmacy; monitoring for adverse drug reactions; educating on how to recognize adverse drug reactions; and advising on when to contact the prescriber. The pharmacist should also implement adherence-promoting measures, such as refill reminders, and encourage recommended vaccinations. These actions help improve clinical outcomes and reduce complications and hospital readmissions.

The American Pharmacists Association has underscored pharmacists’ essential role in optimizing diabetes care.31 Their efforts in medication therapy management, patient-response monitoring, and education strategies have a direct effect on patient outcomes. By emphasizing the importance of adherence to therapy, pharmacists can help lower the risk of complications and hospitalizations and enhance overall health-related quality of life and patient functioning.

By implementing effective patient-education initiatives tailored to the patient’s level of understanding, including both verbal and written information, pharmacists can help improve rates of adherence and empower patients to learn more about diabetes and seek support from available resources. Pharmacists can also assist patients and family members in obtaining information about diabetes and manufacturer-sponsored savings programs for eligible patients to expand access to therapies. Pharmacists should also remind patients about the importance of routine healthcare, including care for any comorbidities. As their multifaceted role in patient care continues to evolve, pharmacists can be a valuable resource for patients with diabetes (TABLE 3).32-34

Published literature on diabetes care highlights the importance of pharmacist involvement in disease management, assessing medication adherence, and educating patients on the correct use of medications for diabetes and comorbidities. A 2018 study revealed that the addition of pharmacists to diabetes care teams improved patient health and reduced healthcare costs and complications.32,33 Pharmacists can be instrumental in making patient-centered clinical recommendations tailored to patient need, provide prescribers and patients with information on available and newly approved therapies for diabetes, optimize medication use, and promote the safety of these medications by monitoring the patient’s response to treatment and minimizing the risk of adverse drug interactions. In a retrospective descriptive study, pharmacist-led diabetes education and management programs significantly improved A1C levels and clinical outcomes in diverse, medically underserved populations.35 The researchers noted that their results add to existing literature evidencing that pharmacists can effectively treat diabetes, including in patient populations with possible barriers to attaining improved health outcomes.35

One study reported that, compared with usual care, pharmacist interventions improved many outcomes, such as in A1C level, blood glucose, blood pressure, lipid profile, medication adherence, and health-related quality of life.36 Another study concluded that community pharmacists are well positioned to support diabetes self-management, leading to improved health outcomes, increased public awareness, and enhanced communication between patients and clinicians; the researchers added that better integration with other healthcare professionals is necessary for maximizing the role of community pharmacists in diabetes care.37 A different study stated that pharmacists play a key role in diabetes management by educating patients, optimizing medication regimens, and collaborating with other healthcare professionals to provide comprehensive care, but added that challenges such as limited resources and adherence issues can impact their effectiveness.38

CONCLUSION

Increased understanding of the pathogenesis of diabetes and advances in its diagnosis, treatment, and management have improved clinical outcomes in many patients, especially those who take an active role in their care and adhere to recommended pharmacologic and nonpharmacologic measures for diabetes control. The ADA’s 2024 Standards of Care are designed to help pharmacists and other clinicians implement effective patient-centered approaches to treating and managing diabetes, which can potentially improve clinical outcomes and prevent or reduce diabetes-related complications, thereby enhancing overall health-related quality of life.

The content contained in this article is for informational purposes only. The content is not intended to be a substitute for professional advice. Reliance on any information provided in this article is solely at your own risk.

REFERENCES

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  3. Dal Canto E, Ceriello A, Rydén L, et al. Diabetes as a cardiovascular risk factor: an overview of global trends of macro and micro vascular complications. Eur J Prev Cardiol. 2019;26(Suppl 2):25-32.
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