ADA Standards of

Medical Care
in Diabetes – 2023
January 2023 Volume 46, Supplement 1

ADA, American Diabetes Association

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ADA STANDARDS OF MEDICAL CARE IN DIABETES – 2023

2023 ADA: Use of Glucose- lowering medications in the management of T2D (Figure 9.3; S147)
Health lifestyle behaviors; Diabetes Self-Management Education and Support (DSMES); Social Determinants of Health (SDOH) TO AVOID
THERAPEUTIC
INERTIA REASSESS
AND MODIFY
TREATMENT
Goal: Cardiorenal risk reduction in high-risk patients with Type-2 diabetes (in addition to comprehensive CV risk management)* Goal: Achievement and maintenance of glycemic and weight management goals
REGULARLY
(3-6 MONTHS)
+ASCVD† +HF Glycemic management: Choose Achievement and maintenance of weight
+Indicators of high risk approaches that provide the efficacy to management goals:
+CKD
Defined differently across CVOTs but all Current or achieve goals:
While definitions vary, most Set individualized weight management goals
included individuals with established CVD prior eGFR<60 mL/min per 1.73 m2 OR
comprise ≥55 years of age with Metformin OR Agent(s) including COMBINATION
(e.g., MI, stroke, any revascularization symptoms albuminuria (ACR ≥3.0 mg/mmol
two or more additional risk therapy that provide adequate EFFICACY to achieve Intensive
procedure). Variably included: conditions of HF with [30mg/g]). These measurements may General lifestyle
evidence-
factors (including obesity, and maintain treatment goals advice: medical Consider
such as transient ischemic attack, unstable document vary over time; thus, a repeat measure is Consider avoidance of hypoglycemia a priority in nutrition
based
medication
Consider
hypertension, smoking, structured metabolic
angina, amputation, symptomatic or ed HFrEF required to document CKD high-risk individuals therapy/eating for weight
dyslipidemia, or albuminuria) patterns/physical
weight
loss
surgery
asymptomatic coronary artery disease. or HFpEF activity
management
program
In general, higher efficacy approaches have
greater likelihood of achieving glycemic When choosing glucose-lowering therapies:
goals Consider regimen with high-to-very-high dual glucose and
+ASCVD/lndicators of High Risk +HF +CKD (on maximally tolerated dose weight efficacy
of ACEi/ARB)
GLP-1 RA# with proven CVD benefit Either
SGLT2i§ with proven CVD benefit SGLT2i § Efficacy for glucose lowering
/ OR
with PREFERABLY
Very high: Dulaglutide (high dose), Semaglutide, Efficacy for weight loss
proven HF SGLT2i§ with primary evidence of
If A1C above target Tirzepatide
benefit in reducing CKD progression Very high: Semaglutide, Tirzepatide
Insulin Combination Oral, Combination injectable
this Use SGLT2i in people with an eGFR ≥20 mL/min
(GLP-1 RA/Insulin)
population per 1.73m2; once initiated should be continued
High: Dulaglutide, Liraglutide
• For patients on a GLP-1 RA, consider incorporating SGLT2i with proven CVD until initiation of dialysis or transplantation
benefit and vice versa OR High: GLP-1 RA (not listed above), Metformin,
• TZD^ SGLT2i, Sulfonylurea, TZD Intermediate: GLP-1 RA (not listed above), SGLT2i
GLP-1 RA with proven CVD benefit if
SGLT2i not tolerated or contraindicated
Neutral: DPP-4i, Metformin
Intermediate: DPP-4i
If A1C above target, for patients on
SGLT2i, consider incorporating a GLP-
1RA and vice versa If A1c above target

Identify barriers to goals:

If additional cardiorenal risk reduction or glycemic lowering needed
• Consider DSMES referral to support self-efficacy in achievement of goals
*In people with HF, CKD, established CVD or multiple risk factors for CVD, the decision to use a GLP-1 RA or SGLT2i with proven benefit should be independent of background use of metformin; † A strong • Consider technology (e.g., diagnostic CGM) to identify therapeutic gaps and tailor therapy
recommendation is warranted for people with CVD and a weaker recommendation for those with indicators of high CV risk. Moreover, a higher absolute risk reduction and thus lower numbers needed to treat are
seen at higher levels of baseline risk and should be factored into the shared decision-making process. See text for details; ^ Low-dose TZD may be better tolerated and similarly effective; § For SGLT2i, CV/ renal • Identify and address SDOH that impact achievement of goals
outcomes trials demonstrate their efficacy in reducing the risk of composite MACE, CV death, all-cause mortality, MI, HHF, and renal outcomes in individuals with T2D with established/high risk of CVD; # For GLP-1
RA, CVOTs demonstrate their efficacy in reducing composite MACE, CV death, all-cause mortality, MI, stroke, and renal endpoints in individuals with T2D with established/high risk of CVD

A1C, glycated hemoglobin; ACEi, angiotensin-converting enzyme inhibitor; ACR, albumin-to-creatinine ratio; ARB, angiotensin receptor blocker; ASCVD, atherosclerotic cardiovascular disease; CGM, continuous glucose monitoring; CKD, chronic kidney disease; CV, cardiovascular;
CVD, cardiovascular disease; CVOT, cardiovascular outcomes trial; DPP-4i, dipeptidyl peptidase 4 inhibitor; eGFR, estimated glomerular filtration rate; GLP-1 RA, glucagon-like peptide 1 receptor agonist; HF, heart failure; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure
with reduced ejection fraction; HHF, hospitalization for heart failure; MACE, major adverse cardiovascular events; MI, myocardial infarction; SDOH, social determinants of health; SGLT2i, sodium-glucose cotransporter 2 inhibitor; T2D, type 2 diabetes; TZD, thiazolidinedione.
Adapted from Davies et al. (45).
American Diabetes Association (ADA). Diabetes Care 2023; 46(Suppl.1): S140–S157 doi: https://doi.org/10.2337/dc23-S009
©2023 Novo Nordisk • For use by field medical employees in scientific exchange
 3 Novo Nordisk®

ADA STANDARDS OF MEDICAL CARE IN DIABETES – 2023

2023 ADA: Use of Glucose- lowering medications in the management of T2D (Figure 9.3; S147)

Health lifestyle behaviors; Diabetes Self-Management Education and Support (DSMES); Social Determinants of Health (SDOH) TO AVOID
THERAPEUTIC
INERTIA REASSESS
AND MODIFY
Goal: Cardiorenal risk reduction in high-risk patients with Type-2 diabetes (in addition to comprehensive CV risk management)* TREATMENT
REGULARLY
(3-6 MONTHS)

+ASCVD†
+Indicators of high risk +HF +CKD
Defined differently across CVOTs but all included
While definitions vary, most comprise ≥55 Current or prior eGFR<60 mL/min per 1.73 m2 OR albuminuria (ACR
individuals with established CVD (e.g., MI, stroke, any
years of age with two or more additional symptoms of ≥3.0 mg/mmol [30mg/g]). These measurements may
revascularization procedure). Variably included:
risk factors HF with vary over time; thus, a repeat measure is required to
conditions such as transient ischemic attack, unstable
( including obesity, hypertension, smoking, documented document CKD
angina, amputation, symptomatic or asymptomatic
dyslipidemia, or albuminuria) HFrEF or HFpEF
coronary artery disease.

+CKD ( on maximally tolerated dose of ACEi/ARB)

+ASCVD/lndicators of High Risk +HF
PREFERABLY
SGLT2i§ with primary evidence of reducing CKD progression
Either SGLT2i § with Use SGLT2i in people with an eGFR ≥20 mL/min per 1.73m2; once
GLP-1 RA# with proven CVD benefit / OR SGLT2i§ with proven CVD benefit proven HF initiated should be continued until initiation of dialysis or
benefit in this transplantation
If A1C above target population OR
GLP-1 RA with proven CVD benefit if SGLT2i not tolerated or
contraindicated
• For patients on a GLP-1 RA, consider incorporating SGLT2i with proven CVD benefit and vice versa
• TZD^ If A1C above target, for patients on SGLT2i, consider
incorporating a GLP-1RA and vice versa

If additional cardiorenal risk reduction or glycemic lowering needed

*In people with HF, CKD, established CVD or multiple risk factors for CVD, the decision to use a GLP-1 RA or SGLT2i with proven benefit should be independent of background use of metformin; † A strong recommendation is warranted for people with CVD and a weaker recommendation for those with indicators of high CV risk. Moreover, a higher absolute risk
reduction and thus lower numbers needed to treat are seen at higher levels of baseline risk and should be factored into the shared decision-making process. See text for details; ^ Low-dose TZD may be better tolerated and similarly effective; § For SGLT2i, CV/ renal outcomes trials demonstrate their efficacy in reducing the risk of composite MACE, CV death, all-
cause mortality, MI, HHF, and renal outcomes in individuals with T2D with established/high risk of CVD; # For GLP-1 RA, CVOTs demonstrate their efficacy in reducing composite MACE, CV death, all-cause mortality, MI, stroke, and renal endpoints in individuals with T2D with established/high risk of CVD

A1C, glycated hemoglobin; ACEi, angiotensin-converting enzyme inhibitor; ACR, albumin-to-creatinine ratio; ARB, angiotensin receptor blocker; ASCVD, atherosclerotic cardiovascular disease; CGM, continuous glucose monitoring; CKD, chronic kidney disease; CV, cardiovascular;
CVD, cardiovascular disease; CVOT, cardiovascular outcomes trial; eGFR, estimated glomerular filtration rate; GLP-1 RA, glucagon-like peptide 1 receptor agonist; HF, heart failure; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction; HHF,
hospitalization for heart failure; MACE, major adverse cardiovascular events; MI, myocardial infarction; SDOH, social determinants of health; SGLT2i, sodium-glucose cotransporter 2 inhibitor; T2D, type 2 diabetes; TZD, thiazolidinedione.
Adapted from Davies et al. (45).
American Diabetes Association (ADA). Diabetes Care 2023; 46(Suppl.1): S140–S157 doi: https://doi.org/10.2337/dc23-S009
©2023 Novo Nordisk • For use by field medical employees in scientific exchange
 4 Novo Nordisk®

ADA STANDARDS OF MEDICAL CARE IN DIABETES – 2023

2023 ADA: Use of Glucose- lowering medications in the management of T2D (Figure 9.3; S147)

Health lifestyle behaviors; Diabetes Self-Management Education and Support (DSMES); Social Determinants of Health (SDOH) TO AVOID
THERAPEUTIC
INERTIA REASSESS
AND MODIFY
Goal: Achievement and maintenance of glycemic and weight management goals TREATMENT
REGULARLY
(3-6 MONTHS)

Glycemic management: Choose approaches that provide the Achievement and maintenance of weight management goals:
efficacy to achieve goals:
Set individualized weight management goals
Metformin OR Agent(s) including COMBINATION therapy that
General lifestyle advice: Intensive evidence- Consider
provide adequate EFFICACY to achieve and maintain treatment goals medical nutrition based structured medication
Consider
Consider avoidance of hypoglycemia a priority in high-risk metabolic
therapy/eating weight management for weight
surgery
individuals patterns/physical activity program loss

When choosing glucose-lowering therapies:

In general, higher efficacy approaches have greater likelihood Consider regimen with high-to-very-high dual glucose and weight efficacy
of achieving glycemic goals

Efficacy for glucose lowering Efficacy for weight loss

Very high: Dulaglutide (high dose), Semaglutide, Tirzepatide Very high: Semaglutide, Tirzepatide
Insulin Combination Oral, Combination injectable (GLP-1 RA/Insulin)
High: Dulaglutide, Liraglutide
Identify barriers to goals:
High: GLP-1 RA (not listed above), Metformin, SGLT2i, Sulfonylurea, TZD
Intermediate: GLP-1 RA (not listed above), SGLT2i
• Consider DSMES referral to support self-efficacy
Intermediate: DPP-4i Neutral: DPP-4i, Metformin in achievement of goals
• Consider technology (e.g., diagnostic CGM) to
identify therapeutic gaps and tailor therapy
• Identify and address SDOH that impact
If A1C above target achievement of goals

A1C, glycated hemoglobin; CGM, continuous glucose monitoring; DPP-4i, dipeptidyl peptidase 4 inhibitor; GLP-1 RA, glucagon-like peptide 1 receptor agonist; SDOH, social determinants of health; SGLT2i, sodium-glucose cotransporter 2 inhibitor; T2D, type 2 diabetes; TZD, thiazolidinedione.
Adapted from Davies et al. (45).
American Diabetes Association (ADA). Diabetes Care 2023; 46(Suppl.1): S140–S157 doi: https://doi.org/10.2337/dc23-S009

©2023 Novo Nordisk • For use by field medical employees in scientific exchange
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ADA STANDARDS OF MEDICAL CARE IN DIABETES – 2023

2023 ADA: Algorithm for intensifying to injectable therapies (Figure 9.4; S150) (1/2)
TO AVOID
Use Principles in Figure 9.3 including reinforcement of behavioral interventions (weight management and physical activity) and provision of THERAPEUTIC
DSMES to meet individualized treatment goals INERTIA REASSESS
AND MODIFY
TREATMENT
REGULARLY
If injectable therapy is needed to reduce A1C1 (3-6 MONTHS)

Consider GLP-1 RA or GIP/GLP-1 RA in most patients prior to insulin2 If already on GLP-1 RA or dual GIP
INITIATION: Initiate appropriate starting dose for agent selected (varies within class) and GLP-1 RA or if these are
TITRATION: Titration to maintenance dose (varies within class) not appropriate OR insulin preferred

If above A1C target

Add basal insulin3

Choice of basal insulin should be based on patient-specific considerations, including cost.
Refer to Table 9.4 for insulin cost information. Consider prescription of glucagon for
emergent hypoglycemia.

Add basal analog or bedtime NPH insulin4

INITIATION: Start 10 IU a day OR 0.1-0.2 IU/kg per day
TITRATION:
• Set FPG target (see Section 6: Glycemic Targets)
• Choose evidence-based titration algorithm, e.g., increase 2 units every 3 days to reach FPG target without hypoglycemia
• For hypoglycemia determine cause, if no clear reason lower dose by 10-20%

Assess adequacy of basal insulin dose

Consider clinical signals to evaluate for overbasalization and need to consider adjunctive
therapies (e.g., basal dose more than ~0.5 units/kg/day, elevated bedtime-morning and/or
post-preprandial
differential, hypoglycemia [aware or unaware], high variability)

1. Consider insulin as the first injectable if evidence of ongoing catabolism, symptoms of hyperglycemia are present, when A1C levels (>10% [86 mmol/mol]) or blood glucose levels (300 mg/dL [16.7 mmol/L]) are very high, or a diagnosis of type 1 diabetes is a possibility.
2. When selecting GLP-1 RA, consider: patient preference, A1C lowering, weight-lowering effect, or frequency of injection. If CVD, consider GLP-1 RA with proven CVD benefit. Oral or injectable GLP-1 RA are appropriate.
3. For patients on GLP-1 RA and basal insulin combination, consider use of a fixed-ratio combination product (iDegLira or iGlarLixi).
4. Consider switching from evening NPH to a basal analog if the patient develops hypoglycemia and/or frequently forgets to administer NPH in the evening and would be better managed with an A.M. dose of a long-acting basal insulin.
A1C, glycated hemoglobin; CVD, cardiovascular disease; DSMES, diabetes self-management education and support; FPG, fasting plasma glucose; GLP-1 RA, glucagon-like peptide 1 receptor agonist; GIP, glucose-dependent insulinotropic peptide; NPH, Neutral Protamine
Hagedorn
American Diabetes Association (ADA). Diabetes Care 2023; 46(Suppl.1): S140–S157 doi: https://doi.org/10.2337/dc23-S009
©2023 Novo Nordisk • For use by field medical employees in scientific exchange
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ADA STANDARDS OF MEDICAL CARE IN DIABETES – 2023

2023 ADA: Algorithm for intensifying to injectable therapies (Figure 9.4; S150) (2/2)

• If above A1C target and not already on a GLP-1 RA or dual GIP and GLP-1 RA, consider these
classes, either in free combination or fixed-ratio combination, with insulin.
• If A1C remains above target:

Add prandial insulin5 If on bedtime NPH, consider converting to

Usually one dose with the largest meal or meal with greatest PPG excursion; prandial twice-daily NPH regimen
insulin can be dosed individually or mixed with NPH as appropriate Conversion based on individual needs and current
INITIATION: glycemic control. The following is one possible
• 4 IU a day or 10% of basal insulin dose approach:
• If A1C <8% (64 mmol/mol) consider lowering the basal dose by 4 IU a day or 10% of basal dose INITIATION:
TITRATION: • Total dose = 80% of current bedtime NPH dose
• Increase dose by 1-2 IU or 10-15% twice weekly • 2/3 given in the morning
• For hypoglycemia determine cause, if no clear reason lower corresponding dose by 10-20% • 1 /3 given at bedtime
TITRATION:
• Titrate based on individualized needs

If above A1C target If above A1C target

Stepwise additional injections of prandial insulin Consider self-mixed/split insulin regimen Consider twice daily premix insulin regimen
(i.e., two, then three additional injections) Can adjust NPH and short/rapid-acting insulins separately INITIATION:
INITIATION: • Usually unit per unit at the same total insulin dose,
• Total NPH dose = 80% of current NPH dose but may require adjustment to individual needs
• 2/3 given before breakfast TITRATION:
Proceed to full basal-bolus regimen • 1/3 given before dinner • Titrate based on individualized needs
(i.e., basal insulin and prandial insulin with each meal) • Add 4 IU of short/rapid-acting insulin to each injection or 10% of reduced NPH dose
TITRATION:
• Titrate each component of the regimen based on individualized needs

5. If adding prandial insulin to NPH, consider initiation of a self-mixed or premixed insulin regimen to decrease the number of injections required.
A1C, glycated hemoglobin; FPG, fasting plasma glucose; GLP-1 RA, glucagon-like peptide 1 receptor agonist; GIP, glucose-dependent insulinotropic peptide; NPH, Neutral Protamine Hagedorn; PPG, postprandial glucose
American Diabetes Association (ADA). Diabetes Care 2023; 46(Suppl.1): S140–S157 doi: https://doi.org/10.2337/dc23-S009

©2023 Novo Nordisk • For use by field medical employees in scientific exchange
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ADA STANDARDS OF MEDICAL CARE IN DIABETES – 2023

2023 ADA: Management of new onset diabetes in youth with overweight or obesity with
clinical suspicion of T2D (Figure 14.1; S243)
Initiate lifestyle management and diabetes education

A1C <8.5% A1C ≥8.5%

Acidosis and/or DKA and/or HHNK
No acidosis or ketosis No acidosis with or without ketosis

• Metformin
• Manage DKA or HHNK
• Metformin • Titrate up to 2000 mg per day as tolerated
• i.v insulin until acidosis resolves, then subcutaneous,
• Titrate up to 2000 mg per day as tolerated • Long-acting insulin: start at 0.5 units/kg/day and titrate
as for type 1 diabetes until antibodies are known
every 2-3 days based on BGM

Pancreatic autoantibodies
NEGATIVE POSITIVE

• Continue or start metformin • Continue or initiate MDI insulin or pump therapy, as for type 1 diabetes
• If on insulin, titrate guided by BGM/CGM values • Discontinue metformin

A1C goals not met

• Continue metformin
• Consider adding GLP-1 RA approved for youth with T2D
• Titrate/initiate insulin therapy; if using long-acting insulin only and glycemic
target not met with escalating doses, then add prandial insulin; total daily
insulin dose may exceed 1 unit/kg/day

A1C 8.5% = 69 mmol/mol. Adapted from the ADA position statement Evaluation and Management of Youth-Onset Type 2 Diabetes2
BGM, blood glucose monitoring; CGM, continuous glucose monitoring; DKA, diabetic ketoacidosis; HHNK, hyperosmolar hyperglycemic nonketotic syndrome; i.v, intravenous; MDI, multiple daily injections.
American Diabetes Association (ADA Diabetes Care 2023; 46(Suppl.1): S230–S253 doi: https://doi.org/10.2337/dc23-S014
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ADA STANDARDS OF MEDICAL CARE IN DIABETES – 2023

2023 ADA: A proposed algorithm for risk stratification in individuals with nonalcoholic fatty
liver disease (NAFLD) or nonalcoholic steatohepatitis (NASH). (Figure 4.2; S58)

Noninvasive testing for fibrosis (FIB-4 or NFS)

Low Risk Indeterminate Risk High Risk

Vibration-controlled transient elastography or

Repeat in 2-3 years
blood tests measuring fibrosis markers

Low Risk High Risk

Refer to a
Repeat in 2-3
gastroenterologist
years
or hepatologist

American Diabetes Association (ADA). Diabetes Care 2023; 46(Suppl.1): S49–S67. doi: https://doi.org/10.2337/dc23-S005

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