This transcript has been edited for clarity. For more episodes, download the Medscape app or subscribe to the podcast on Apple Podcasts, Spotify, or your preferred podcast provider.
Carol H. Wysham, MD: Hello, I'm Dr Carol Wysham. Welcome to season three of the Medscape InDiscussion Type 2 Diabetes podcast series. Today, we'll discuss the 2025 updates of the American Diabetes Association (ADA) Standards of Care and Diabetes.
First, let me introduce my guest, Dr Rozalina G. McCoy. Dr McCoy is an associate professor in the University of Maryland School of Medicine's Division of Endocrinology, Diabetes, and Nutrition, where she also serves as associate division chief for clinical research and the director of the Precision Medicine and Population Health Program in the University of Maryland Institute for Health Computing. She has served as a co-chair of the ADA Professional Practice Committee (PPC). This is a committee that drafts the annual standards of medical care for people with diabetes. She has chaired the 2025 updates and is also chair for the 2026 updates. Dr McCoy, welcome to the Medscape InDiscussion Type 2 Diabetes podcast.
Rozalina McCoy, MD, MS: Thank you so much. It's wonderful to be with you today.
Wysham: You have been chairing the professional practice committee (PPC), and I think the audience would be interested in hearing just a little bit about the process that you go through to update the ADA standards of care every year.
McCoy: This is a team effort that's led by the ADA PPC with the support of an incredible ADA staff. The PPC is an interprofessional expert committee with physicians, nurse practitioners, pharmacists, diabetes care and education specialists, dieticians, behavioral health specialists, and others who have collective expertise in all aspects of diabetes management. We first meet in January and get to work in early February, just a few weeks after the prior year's update is released. Throughout the spring and summer, as you're hopefully reviewing and learning from the most recent standards of care, the PPC members dive into the literature to identify the major innovations in diabetes care, the key ongoing trials that are expected to be completed by July or so of the year, new drug and technology approvals and label changes, and importantly, the feedback and commentary that the ADA has received on the published standards of care and the living standards.
We meet regularly through the spring and summer as subgroups of each section. Then, the entire PPC meets for a 2-day long working meeting to discuss the available emerging evidence and reach a consensus on all the recommendations and the level of evidence for each. Once that is finalized, we begin working and writing. In the end, all PPC members review and approve the final version of the standards of care, which is what you read today.
Wysham: That's very helpful. Thank you. Over the past several years, the standards of care have really emphasized putting the patient at the center of the decision-making and the care of the person with diabetes. And, of course, one important aspect of this is the importance of treating the whole person.
You could probably spend the entire 30 minutes talking about what that means, but could you perhaps talk about what you think are the most important additions from this year?
McCoy: I am so glad you asked this, because this is exactly the message we hope that all healthcare professionals caring for people with diabetes or otherwise involved in their care take away from the standards of care. People living with diabetes are people first. They have other chronic health conditions that require attention and management and are impacted by the context and circumstances in which they live and receive care. They have different goals and preferences for care. It's important that the standards of care support a framework for high-quality, evidence-based, and comprehensive care that's individualized to meet each person's needs. There are a number of updates in the standards of care that really seek to do this. I wish we had time to talk about all of them, but I'll mention a few.
First, we expanded section 4, which focuses on the comprehensive medical evaluation and assessment of comorbidities, to include two new sections. The first is a subsection on dental care. We recommend that people with diabetes should have a dental exam at least once a year because periodontal disease is both more prevalent and more severe in people with diabetes. It is also important to coordinate efforts between the medical and dental teams to adjust glucose-lowering medications before and after dental treatment to avoid hypoglycemia if the person with diabetes isn't able to eat.
The second new subsection addresses, for the first time, the important topic of female sexual dysfunction. Female sexual dysfunction is very common. It's as common as sexual dysfunction is in men. Women are significantly less likely to discuss their concerns with their clinicians and to have them addressed. We recommend that clinicians screen all women with diabetes or prediabetes for desire, arousal, and orgasm difficulties and signs and symptoms of genitourinary syndrome of menopause. Treatment of these conditions is multifaceted and the same as for women without diabetes but includes an additional focus on glycemic management. So, the most important step here is to screen and detect female sexual dysfunction so it can be addressed.
Finally, through the entire standards of care, we added important considerations for medication management in individuals of childbearing potential. We talk about the importance of contraception counseling, something that hasn't really been a part of routine diabetes care conversations. Still, it's incredibly important since the prevalence of diabetes, especially type 2 diabetes among younger individuals, has increased in the past few decades. Many glucose-lowering, lipid-lowering, and blood pressure-lowering medications are not recommended for use during pregnancy. The standards of care provide guidance on what to do for each of these medication categories.
For glucose-lowering medication specifically, discussions should touch upon glycemic goals prior to conception, the time frame for stopping non-insulin glucose-lowering medications, and the optimal glycemic management in preparation for pregnancy if desired. Then, because GLP-1 receptor agonists and the dual GIP/GLP-1 receptor agonist may affect the absorption of orally administered medications, including oral contraception, especially when you first start or increase the dose, we recommend that individuals use a second form of contraception until the maintenance dose of these medications is achieved for at least 4 weeks.
Wysham: This document contains a lot of information about the use of medications associated with weight loss. Can you review some of the recommendations regarding diet and exercise in patients who are taking medications associated with weight loss or those who have had bariatric surgery?
McCoy: It's really exciting to have so many effective treatment options for the management of obesity. But this also means that we have to work with our patients to make sure that they achieve and maintain their weight goals safely. We stress the importance of physical activity, particularly strength training, for adults and youth who are receiving weight management pharmacotherapy or who have had metabolic surgery. Weight loss, whether with pharmacotherapy or with metabolic surgery, induces both fat mass loss and the loss of lean body mass. This can lead to the development or worsening of frailty and sarcopenic obesity. If individuals who lose weight with treatment later regain weight, this weight is often regained predominantly as fat mass, and without strength training, very little lean body mass can be rebuilt. Strength training during weight loss minimizes the amount of lean body mass that is lost, preferentially supporting the loss of fat mass. It's also very important for weight maintenance after weight loss. I stress to my patients that both aerobic and resistance or strength training physical activity are imperative for glycemic management, weight management, and overall health.
It's also important to screen individuals who've been treated with GLP-1 receptor agonists or the dual GIP/GLP-1 receptor agonist and those who have had metabolic surgery for malnutrition, which can occur in individuals of varying weight status, including those with obesity. So people who have lost more than 20% of body weight or lost weight rapidly, more than 4kg a month, should definitely be screened for malnutrition. We offer some suggestions in the standard of care for how to do that. One suggested screening tool is the Simplified Nutritional Appetite Questionnaire (SNAQ), which includes a few simple questions about appetite, food intake, and changes in eating habits. If there's a concern for malnutrition, it's important to screen for nutritional deficiencies and, of course, engage a registered dietician/nutritionist to help our patients prevent malnutrition.
Wysham: How do you address the question about whether weight-reducing medications can be stopped once a patient reaches their goal weight?
McCoy: This question comes up very often in my practice, especially as we're seeing drug shortages or limited insurance coverage for the most effective weight management medications like semaglutide and tirzepatide. So broadly, we recommend that weight management medications that are indicated for chronic therapy, so everything other than phentermine monotherapy, should be continued beyond reaching weight loss goals to maintain all the health benefits of weight loss. Sudden discontinuation of weight management medications often results in weight regain and worsening of cardiometabolic risk factors like A1C, lipids, and blood pressure. Clinical trials have shown that sudden discontinuation of semaglutide and tirzepatide results in a regain of half to two-thirds of the weight loss within a year, but we do not yet have robust data on what to do when weight loss goals are achieved, and the new goal is weight maintenance without further weight loss.
It's important to engage our patients in shared decision-making and talk through the potential options, such as continuing the current pharmacotherapy at the lowest effective dose that is possible, switching to a less potent and typically less costly weight loss medication, or potentially even stopping medication if coupled with optimized lifestyle management and close monitoring of weight. However, this decision really needs to be individualized for each person. It may require trialing different approaches to find one that is best for a given patient.
Wysham: Those are really good recommendations, and I appreciate hearing your perspective on this. On the topic of incretin therapies, many of us have struggled to help our patients access these medications in the face of cost and shortages. Can you review the recommendations on what considerations we might have for our patients when they cannot access these medications?
McCoy: Unfortunately, both of these scenarios come up in nearly every clinic visit. In section nine, we provide recommendations for dealing with medication unavailability, whether it is because a medication is in shortage, like we have seen over the past 2 years with many GLP-1 receptor agonists or tirzepatide, or because of recalls, like we have seen with metformin, for example.
So when the medication is in shortage and when the prescription medication is not covered by insurance, some have turned to compounding pharmacies and outsourcing compounding facilities. But unfortunately, there have been many safety, quality, and effectiveness concerns with compounded products. It's important to recognize that compounded GLP-1s are not an exact copy of the FDA-approved product because there's no available standard or chemical instruction guide for compounders to use to replicate the FDA-approved product. The compounded drugs are often salt versions of the FDA-approved drug or come with additives that may impact effectiveness and safety and come in different doses and concentrations, leading to dosing errors and, ultimately, harm. Therefore, we do not recommend the use of compounded products that are not approved by the FDA.
If a glucose-lowering medication is not available, the next best thing is to switch to another medication in the same class or a different class but with a similar efficacy and safety profile. When the original medication is once again available, we should reassess whether it's best for the individual to resume taking it or to stay on the new treatment plan if it works best for them.
Cost is another important consideration. The ADA has and continues to advocate for affordable and accessible medications, insulin, and technology. There have also been several recent policy changes that lowered out-of-pocket insulin costs for many patients, typically to 35 dollars per month for insulin. We talk a lot about this in section one and also throughout the standards of care whenever we talk about potentially costly medications. We have content with guidance on identifying cost reduction strategies, such as copayment reduction cards and patient assistance programs, and encourage clinicians to work with other members of their teams, pharmacists, social workers, diabetes care and education specialists, who can be invaluable resources to help our patients afford and access the treatments they need.
Wysham: That has been a frustrating experience for us in our clinical practice as well. Over the past several years, the recommendations for how and why we choose glucose medications have changed radically. The new emphasis has been to choose medications based on patient comorbidities to try to either prevent the complications or prevent the mortality and morbidity of complications rather than focusing solely on glycemic control.
This fits into the framework of whole-person care. Can you comment on some of the important patient characteristics that we should be considering when choosing an anti-hyperglycemic therapy?
McCoy: You are absolutely right. Our first priority in treating type 2 diabetes is preventing both short-term and long-term complications. The choice of therapy is guided by the individualized prioritization of the need to prevent atherosclerotic cardiovascular events like MIs or stroke, reducing heart failure symptoms or hospitalizations, reducing heart failure symptoms and hospitalizations, limiting the progression of chronic kidney disease, minimizing the impact of metabolic dysfunction-associated steatotic liver disease (MASLD), and supports weight management. Section nine of the standards of care is the most complex. It's also the most viewed and downloaded of all the standards of care. We simplified and streamlined the pharmacotherapy algorithm to hopefully make it more user-friendly. Also, to incorporate new evidence on the optimal treatment of type 2 diabetes in patients with MASLD and metabolic dysfunction-associated steatohepatitis (MASH).
Adults with type 2 diabetes and established or high risk of atherosclerotic cardiovascular disease should be preferentially treated with GLP-1 receptor agonist or SGLT2 inhibitors for both glycemic management and for atherosclerotic cardiovascular disease risk reduction, irrespective of A1C. There have been no head-to-head studies examining which of these two medication classes is preferred in this context. The observational studies suggest them to be comparable. We recommend a shared decision-making approach and consideration of the other health needs that may need to be addressed at the same time.
Similarly, people with heart failure, either reduced or preserved ejection fraction, should be preferentially treated with SGLT2 inhibitors for both glycemic management and prevention of heart failure hospitalizations. New this year is the recommendation to consider using GLP-1 receptor agonists in individuals with type 2 diabetes, symptomatic heart failure with preserved ejection fraction, and obesity to reduce heart failure-related symptoms. For individuals with chronic kidney disease, who have glomerular filtration rate (GFR) between 20 and 60, or who have albuminuria, we can use either SGLT2 inhibitors or GLP-1 receptor agonists for both glucose lowering, slowing the progression of chronic kidney disease and a reduction of cardiovascular disease risk. However, it's important to note that the glycemic benefits of SGLT2 inhibitors are diminished once GFR is below 45. In this context, we still use SGLT2s for kidney protection and cardiovascular risk reduction rather than glucose lowering.
In individuals with chronic kidney disease whose GFR is less than 20, GLP-1s are preferred for glycemic management due to their low risk for hypoglycemia and cardiovascular risk reduction. Now, stressed newly this year, for those with MASLD, MASH, or high risk for liver fibrosis based on non-invasive tests, GLP-1 receptor agonists, the dual GIP/ GLP-1 receptor agonists, or pioglitazone are preferred for glycemic management. However, pioglitazone may not be a good option if the patient also has obesity. Combination therapy with pioglitazone and GLP-1 receptor agonists can be considered with biopsy-proven MASH. And then, as before, it's important to avoid hypoglycemia-prone medications, particularly in those at highest risk for adverse sequela of hypoglycemia. And to choose medications with the appropriate efficacy to achieve glycemic and weight management goals. In the algorithm in section 9, we provide relative potencies of the available medications for each of these objectives to help choose the best medication for a given patient.
Wysham: I was actually a chair of the PPC when we first attempted to come up with an algorithm way back in 2012. I know in your practice and mine that we are using continuous glucose monitoring (CGM) in our patients with type 2 diabetes on insulin. Can you review the new recommendations surrounding the use of a CGM in patients with type 2 diabetes when they're not on insulin?
McCoy: This was an important update, which reflects the increasing body of evidence supporting the benefits of CGM use in the management of type 2 diabetes. We recommend that clinicians consider using CGM in adults with type 2 diabetes treated with glucose-lowering medications other than insulin to achieve and maintain their individualized glycemic goals, and this is level B evidence. Multiple clinical trials and observational studies have shown that CGM, compared to blood glucose monitoring, results in greater improvements in A1C, time and range, time below range, and time above range, as well as greater user-reported satisfaction. CGM can also support positive behavior changes and food choices and, therefore, can support weight management. However, we don't yet have the evidence to extend this recommendation to people meeting glycemic goals without the use of glucose-lowering medications.
Wysham: What about CGM in the hospital setting?
McCoy: We do recommend that patients who are hospitalized and using CGM or insulin pumps or automated insulin delivery (AID) systems, that their CGMs, pumps, and AIDs be continued as clinically appropriate. Several studies have shown that inpatient use of CGMs can help detect and prevent hypoglycemia. However, CGMs are not currently FDA-approved for inpatient use. We need to use confirmatory point-of-care glucose testing for insulin-dosing decisions and hypoglycemia assessment. And, of course, the use of any diabetes technology in the hospital is predicated on the local availability of necessary supplies, resources, training, ongoing competency assessments, and implementation of diabetes technology protocols.
Wysham: Believe it or not, I started my career before they started using finger sticks in the hospital. We had a several-year process to try to convince the hospitals that they should be doing that. This is a flashback to that time.
We are increasingly aware that the categorization of diabetes isn't always straightforward. Can you discuss the issue of atypical presentations of type 1 and type 2 diabetes? How can they be characterized, and what should be done if the diagnosis is unclear?
McCoy: This is a really important point. Diabetes is not a single entity, right? It's a group of metabolic disorders that's collectively characterized by the underutilization of glucose as an energy source and an overproduction of glucose with increased gluconeogenesis and glycogenolysis. It's not as simple as someone definitely has type 1 diabetes or type 2 diabetes. We should suspect type 1 diabetes in individuals who are diagnosed at a younger age. We generally think about 35 years or younger, with a personal or family history of autoimmunity, with a lean body habitus, and with a family history of type 1 diabetes. Those who don't respond as expected to non-insulin therapies or who have been treated with medications like immune checkpoint inhibitors for cancer that cause type 1 diabetes. However, these rules of thumb do not always rule out type 1 diabetes if they aren't present. Because both type 1 and type 2 diabetes can present at any age, they can and do develop in individuals of different body types, including those who have obesity. And can present with variable degrees of acuity.
I'm sure we can all think of young adults presenting with ketoacidosis (DKA) and ultimately confirmed to have type 2 diabetes who can be successfully tapered off of insulin after initial treatment of their DKA. Similarly, older individuals, including those with relatively slow progression to insulin dependency, who we discover to have type 1 diabetes. So, in any patient in whom we suspect type 1 diabetes, we need to test for islet autoantibodies, and we should check multiple antibodies because one may be negative. We check GAT65, IA2, zinc transporter 8, and islet cell antibodies. If antibodies are positive, we establish the diagnosis of type 1 diabetes, and we consider latent autoimmune diabetes in adults to be kind of a type of type 1 diabetes in this context because, ultimately, patients require insulin therapy.
If these are negative but the index of suspicion is high, we also check C peptide, just not in the context of recent DKA, and make sure the blood glucose levels are slightly elevated. And if the C peptide is under 200 picomoles per liter, this, too, confirms the diagnosis of type 1 diabetes. Ultimately, if we're not sure, we treat based on the clinical scenario, provide patients with the tools to monitor their glucose levels closely, follow them regularly in the clinic, and reassess in the future.
Wysham: Today, we talked to Dr Rozalina McCoy about updates to the standards of medical care for patients with diabetes. Thank you for tuning in. Please take a moment to download the Medscape app to listen and subscribe to this podcast series on type 2 diabetes. This is Dr Carol Wysham for the Medscape InDiscussion Type 2 Diabetes Podcast.
Listen to additional seasons of this podcast.
Resources
Standards of Care in Diabetes-2025
9. Pharmacologic Approaches to Glycemic Treatment: Standards of Care in Diabetes-2025
1. Improving Care and Promoting Health in Populations: Standards of Care in Diabetes-2025
Medscape © 2025 WebMD, LLC
Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.
Cite this: 2025 ADA Updates: Comorbidities, Dental Care, Weight Loss, Sexual Dysfunction, and CGM Use for Type 2 Diabetes - Medscape - Mar 25, 2025.
Comments