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2021 Updates to the ADA Standards of Care

By Julia Kenney and Frida Velcani

The American Diabetes Association recommends SGLT-2 inhibitors or GLP-1 agonists for people with heart and kidney problems, the use of Time in Range in diabetes management, and continuous glucose monitors for all people with diabetes on multiple daily injections or pump therapy. It also encourages healthcare professionals to consider social determinants of health, refer people to diabetes self-management education services, and reduce barriers to care. 

The American Diabetes Association (ADA) recently released its 2021 Standards of Medical Care, which provides healthcare professionals, researchers, and insurers with updated guidelines on diabetes care and management. These recommendations were developed by a panel of experts who built upon prior Standards be reviewing the latest and most significant scientific research. We are excited by many of the updates in this year’s issue, especially the expansion of the Diabetes Metrics section to include Time in Range (TIR).

Since the Standards of Care document is quite technical and geared towards healthcare professionals, here’s a summary of some of the updates. We’ve included detailed explanations below. If you think any of these updates may apply to you, we encourage you to talk with your diabetes care professional.

Diabetes therapy:

Two types of glucose-lowering medications for people with type 2 diabetes – GLP-1 agonists and SGLT-2 inhibitors – can support the health of the heart and kidneys. ADA now recommends that healthcare professionals consider prescribing these medications to reduce health complications, regardless of someone’s A1C level or metformin use. Some SGLT-2 inhibitors have also been shown to support heart health in people who don’t have diabetes. Talk with your healthcare team about the benefits that these drugs may provide for your heart and kidneys.

Two drugs used to reduce high blood pressure for people with diabetes – ACE inhibitors and angiotensin receptor blockers – were also found to help treat coronary artery disease.

Diabetes technology:

For many years ADA has recommended that people with diabetes get their blood glucose tested two to four times a year using an A1C test. We are excited that this year the updated Standards include recommendations for Time in Range (TIR) and Time Below Range. Time in Range has proven to be a valuable measurement in diabetes care – learn more here and ask your healthcare professional how using Time in Range can improve your diabetes management.

The Standards were also updated to include continuous glucose monitoring (CGM) for all people with diabetes injecting insulin more than once a day or using an insulin pump.

Diabetes care:

Our health is affected by many factors in our environment. The update to this year’s Standards of Care underlines that healthcare professionals should consider someone’s access to healthy food, housing, social support, and ability to afford medications among other social determinants of health (SDOH) in their treatment decisions and care practices. The update also underscored the impact that language has in the clinical setting by suggesting the use of words that avoid judgment in obesity management and care.

Finally, ADA recommends diabetes self-management education and support (DSMES) for all people with diabetes, removal of barriers to care, and routine vaccination for people with diabetes.

These are some highlights of this year’s ADA recommendations to healthcare professionals who treat and care for people for diabetes. Read on for more detailed explanations, as well as links to resources from diaTribe and ADA.

ADA recommends GLP-1 agonists or SGLT-2 inhibitors for heart and kidney health in people with type 2 diabetes, independent of A1C or metformin use.

SGLT-2 inhibitors and GLP-1 agonists are glucose-lowering drugs that are approved for people with type 2 diabetes, which have been shown to improve cardiovascular (heart) health outcomes. Last year, ADA recommended GLP-1 agonists and SGLT-2 inhibitors to improve heart and kidney health in people with diabetes no matter their A1C. This year, the recommendation for these medications is independent of both A1C and metformin use. This means that in some cases, GLP-1 agonists and SGLT-2 inhibitors are recommended for people with type 2 diabetes who are not being prescribed metformin. However, metformin remains the first-line therapy recommendation for individuals with type 2 diabetes.

SGLT-2 inhibitors are also recommended for people with type 2 diabetes and heart failure. This addition to the Standards of Care is based on results from the DAPA-HF trial, in which the SGLT-2 inhibitor, Farxiga, was shown to improve cardiovascular outcomes for people with heart failure, whether or not they had diabetes. Farxiga reduced the risk of cardiovascular complications by 26% for these individuals.

These updates are posted in chapter 10 of the 2021 ADA Standards of Care. Click to learn more about the use of SGLT-2 and GLP-1 medications for heart health.

With regards to cardiovascular complications and chronic kidney disease (CKD), ADA now strictly recommends SGLT-2 inhibitors for people with heart failure and prefers SGLT-2 inhibitors for people with CKD. In addition, GLP-1 agonists should be considered for people with kidney disease, particularly if an SGLT-2 is not tolerated. These updates are posted in chapter 9 of the 2021 ADA Standards of Care.

ACE inhibitors and angiotensin receptor blockers (ARBs) are recommended for hypertension in people with type 2 diabetes and coronary artery disease (CAD).

ACE inhibitors and ARBs are used to reduce blood pressure in people with diabetes. ADA is now recommending these medications as the first line of defense for high blood pressure in people with coronary artery disease.

During pregnancy, the recommended blood pressure target was reduced to 110-135/85 mmHg, to reduce the risk of hypertension associated with pregnancy.

These updates are posted in chapter 10 of the 2021 ADA Standards of Care.

Healthcare professionals are warned of potential “overbasalization” for people on insulin.

Too much insulin, referred to as “overbasalization,” occurs when basal insulin doses are too high (mainly to target fasting glucose levels and often to compensate for insufficient bolus insulin with meals).  In this year’s Standards of Care, ADA included some warning signs and complications associated with overbasilization. ADA’s new clinical signals of overbasalization include basal doses of more than 0.5 IU/kg, large differences in bedtime and morning glucose levels, large differences in glucose levels before and after meals, hypoglycemia, and high glucose variability.

These updates are posted in chapter 9 of the 2021 ADA Standards of Care.

Time in Range (TIR) is validated as an important glucose measure. ADA now recommends A1C below 7% or TIR above 70%, and time below range lower than 4% for most adults.

In previous years, the Standards of Care included an “A1C Testing” subsection that recommended people with diabetes test their A1C two to four times a year with an A1C target below 7%. This year, the subsection was re-titled “Glycemic Assessment” and now includes both the A1C recommendations and recommendations for Time in Range and Time Below Range. The goal is to be in the target range (70-180 mg/dl) more than 70% of the time, with less than 4% of time spent below range (under 70 mg/dl). However, the target glucose range varies based on the person with diabetes. Time in Range has proven to be a valuable metric in diabetes care – learn more here.

These updates are posted in chapter 6 of the 2021 ADA Standards of Care.

CGM is recommended for all people with diabetes on multiple daily injections of insulin or pump therapy.

Continuous glucose monitoring (CGM) has been shown to help people with diabetes improve their daily diabetes management and achieve positive long-term health outcomes. Previously, CGM was only proposed for people who did not meet glucose targets, had hypoglycemia unawareness, or experienced hypoglycemia. These recommendations have since been expanded to include everyone using rapid-acting insulin. Guidelines for addressing skin reactions due to CGM adhesives have also been incorporated into the Standards of Care.

These updates are posted in chapter 7 of the 2021 ADA Standards of Care.

Social determinants of health should be assessed in population health, medical evaluation, obesity management, and care of youth.

A person’s health can be affected by many factors in their environment. Given that not every person has equal access to care or equitable outcomes, healthcare professionals are encouraged to consider social determinants of health (SDOH) when making treatment decisions. This includes consideration of the person’s access to healthy food, housing, social support, and ability to afford medications. ADA recommends doing a “social life assessment” at the initial and annual diabetes evaluation visits. In obesity management, it is also suggested that healthcare professionals use nonjudgmental, people-first language (e.g., saying “person with obesity” rather than “obese person”).

These updates are posted in chapters 1, 4, 8, and 13 of the 2021 ADA Standards of Care.

Diabetes self-management education and support is recommended for all people with diabetes.

Behavioral health describes the impact that a person’s activity, habits, and behavior might have on their physical and mental well-being. Diabetes self-management education and support (DSMES) has been shown to promote effective behavior management and help people with diabetes achieve their treatment goals. The 2020 diabetes self-management education (DSMES) consensus report for adults with type 2 diabetes provides healthcare professionals with recommendations on how to deliver effective diabetes education and remove barriers to care. These guidelines are echoed by the 2021 Standards of Care. Also included are an emphasis on telemedicine use and the recommendation that healthcare professionals evaluate the need for DSMES at four important times:

  • At diagnosis;

  • Once a year (or more often) if someone is not meeting their treatment goals;

  • If health complications arise;

  • When transitions in life and care occur.

These updates are posted in chapter 5 of the 2021 ADA Standards of Care.

The importance of routine vaccinations for people with diabetes is highlighted, especially during the COVID-19 pandemic.

The Standards of Care advocates for a cadence of vaccination for people with diabetes. The updates include a table with the CDC-recommended vaccinations for people with diabetes. Though a COVID-19 vaccine had not yet become widely available outside of clinical trials at the time these updates were written, ADA strongly advises that people with diabetes be one of the first populations in line for vaccination. As it stands, people with type 2 diabetes or obesity will be eligible for early vaccination in the US in the coming months. This does not appear to be the case for those with type 1 diabetes, since at this time they are not considered as a high priority. 

These updates are posted in chapter 4 of the 2021 ADA Standards of Care.

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