ADA Standards of Care in Diabetes — 2026
Organ-protection-first approach to type 2 diabetes: choose therapy by cardiorenal profile, not by A1c alone, and integrate CGM and tirzepatide across the care spectrum.
What changed in this edition
- GLP-1 RA or dual GIP/GLP-1 (tirzepatide) preferred second agent after metformin for most adults with T2D.
- Tirzepatide endorsed for weight management and glycemic control; semaglutide 2.4 mg reaffirmed for obesity.
- CGM recommended for all adults on insulin and for selected non-insulin-treated T2D with hypoglycemia risk.
- A1c individualization band formally widened: <7% default, <6.5% if safe, <8% in frail/limited-life-expectancy.
- Screening for MASH/steatotic liver disease with FIB-4 at least annually in T2D.
- Finerenone integrated for CKD with albuminuria regardless of A1c.
- Teplizumab reaffirmed for delaying stage 3 T1D in stage 2 relatives with dysglycemia.
- Updated obesity-first framing: treat adiposity-based chronic disease as the driver of T2D.
Clinical takeaways
Pick therapy by comorbidity
ASCVD or high risk: GLP-1 RA with proven CV benefit or SGLT2i. Heart failure or CKD: SGLT2i. Obesity dominant: tirzepatide or semaglutide 2.4 mg. A1c not the first filter.
CGM deployment
All T1D; all T2D on any insulin; T2D without insulin if hypoglycemia risk, pregnancy, or motivation for lifestyle change. Target time-in-range 70–180 mg/dL >70%; time-below-range <4%.
Weight as a primary target
5–15% weight loss improves most T2D outcomes; ≥15% can induce remission in early T2D. Match intensity to BMI, comorbidity, and tolerability; metabolic surgery remains an option at BMI ≥30 with inadequate control.
Liver and kidney screening
FIB-4 annually; if indeterminate or high, proceed to elastography. Annual uACR and eGFR; start SGLT2i at eGFR ≥20 and finerenone per KDIGO criteria.
Hypoglycemia prevention
Review insulin and sulfonylurea regimens at every visit; de-intensify when A1c well below individualized target, especially in older adults. Structured glucagon access (including nasal/auto-injector).
Supporting trials
- SURPASS-4PubMed 34672967
Tirzepatide outperformed insulin glargine for A1c and weight in T2D with high CV risk.
- SURMOUNT-1PubMed 35658024
Tirzepatide produced up to 22.5% weight loss in adults with obesity without diabetes.
- STEP-1PubMed 33567185
Semaglutide 2.4 mg achieved 14.9% weight loss at 68 weeks.
- SELECTPubMed 37952131
Semaglutide reduced MACE by 20% in adults with obesity and established CVD without diabetes.
- TN-10 / TeplizumabPubMed 31180194
Teplizumab delayed progression to stage 3 T1D by a median of ~2 years.
Related reading
Type 2 Diabetes Management 2026: ADA Standards of Care Updates
The 2026 ADA Standards of Care introduce updated guidance on GLP-1 agonist and GLP-1/GIP dual agonist positioning, cardiovascular risk reduction, and technology-assisted management. Key changes for primary care and endocrinology practice.
Evidence-Based MedicineSGLT2 Inhibitors in HFpEF with CKD: What the Evidence Shows
A 72-year-old with HFpEF, eGFR 34, type 2 diabetes, and a recent heart failure hospitalization. Should she start an SGLT2 inhibitor? The answer spans three trial programs, and the data are clearer than you might expect.
Clinical AIDiabetic Kidney Disease: Finerenone, Nonsteroidal MRAs, and the FIDELIO/FIGARO Evidence
Finerenone, the first nonsteroidal mineralocorticoid receptor antagonist, has demonstrated cardiorenal benefit in DKD beyond SGLT2 inhibitors and RAS blockade. This review covers the FIDELIO-DKD and FIGARO-DKD trials, practical implementation, and the emerging multi-pillar approach to DKD management.