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Diabetes mellitus type 2

What's new

Updated 2025 ADA guidelines for the diagnosis and management of type 2 diabetes .

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of diabetes mellitus type 2 are prepared by our editorial team based on guidelines from the American Diabetes Association (ADA 2025), the American Academy of Family Physicians (AAFP 2024), the American College of Physicians (ACP 2024), the Canadian Cardiovascular Society (CCS/CAIC 2024), the Diabetes Canada (DC 2024), the Endocrine Society (ES ...
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Screening and diagnosis

Indications for screening, general population: as per ADA 2025 guidelines, consider screening for prediabetes and T2DM in asymptomatic adults of any age with overweight or obesity (BMI ≥ 25 kg/m² or ≥ 23 kg/m² in Asian American individuals) having one or more of the following risk factors:
first-degree relative with diabetes
high-risk race, ethnicity, or ancestry, such as African American, Latino, Native American, Asian American
history of CVD
hypertension (≥ 130/80 mmHg or on therapy for hypertension)
HDL-C < 35 mg/dL (< 0.90 mmol/L) and/or triglycerides > 250 mg/dL (> 2.8 mmol/L)
females with PCOS
physical inactivity
other clinical conditions associated with insulin resistance (such as severe obesity, acanthosis nigricans, MASLD).
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  • Indications for screening (choice of test)

  • Indications for screening (specific conditions)

  • Indications for screening (gestational diabetes mellitus)

  • Diagnosis

Classification and risk stratification

Diabetes classification: as per ADA 2025 guidelines, classify patients with hyperglycemia into appropriate diagnostic categories to aid in personalized management.
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  • Cardiovascular risk assessment

Diagnostic investigations

General principles: as per ADA 2025 guidelines, ensure a person-centered communication style using culturally sensitive and strength-based language and active listening, eliciting individual preferences and beliefs, and assessing literacy, numeracy, and potential barriers to care to optimize health outcomes and health-related QoL.
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  • HbA1c and blood glucose

  • Assessment for hypoglycemia

  • Assessment for hyperglycemic crises

  • Screening for obesity

  • Screening for hypertension

  • Screening for CVD

  • Screening for PAD

  • Screening for dyslipidemia

  • Screening for MASLD

  • Screening for diabetic nephropathy

  • Screening for diabetic retinopathy

  • Screening for diabetic neuropathy

  • Screening for diabetic foot

  • Screening for osteoporosis

  • Screening for disability

  • Screening for anxiety and depression

  • Screening for cognitive impairment

  • Screening for serious mental illnesses

  • Screening for sleep disorders

  • Screening for disordered eating behavior

  • Screening for malnutrition

  • Screening for sexual dysfunction (males)

  • Screening for sexual dysfunction (females)

  • Screening for dental issues

Medical management

General principles: as per ESC 2023 guidelines, identify and treat risk factors and comorbidities early.
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  • Glycemic targets

  • Initial therapy (general principles)

  • Initial therapy (metformin)

  • Initial therapy (SGLT-2 inhibitors and GLP-1 receptor agonists)

  • Initial therapy (treatment monitoring)

  • Initial therapy (treatment intensification)

  • Insulin therapy (indications)

  • Insulin therapy (choice of agent)

  • Insulin therapy (delivery systems)

  • Insulin therapy (monitoring)

  • Management of hypoglycemia

  • Management of obesity

  • Management of hypertension (BP targets)

  • Management of hypertension (lifestyle modifications)

  • Management of hypertension (pharmacotherapy)

  • Management of hypertension (monitoring)

  • Prevention of CVD (glucose-lowering medications)

  • Prevention of CVD (lipid-lowering therapy)

  • Prevention of CVD (antiplatelet therapy)

  • Management of CVD (glucose-lowering medications)

  • Management of CVD (lipid-lowering therapy)

  • Management of CVD (antihypertensives)

  • Management of CVD (revascularization)

  • Management of HF

  • Management of dyslipidemia (lipid targets)

  • Management of dyslipidemia (lifestyle modifications)

  • Management of dyslipidemia (statin therapy)

  • Management of dyslipidemia (non-statin lipid-lowering therapy)

  • Management of dyslipidemia (hypertriglyceridemia)

  • Management of dyslipidemia (lipid profile monitoring)

  • Management of MASLD (lifestyle changes)

  • Management of MASLD (glucose-lowering medications)

  • Management of MASLD (insulin therapy)

  • Management of MASLD (thyroid hormone receptor-beta agonists)

  • Management of MASLD (statin therapy)

  • Management of MASLD (bariatric surgery)

  • Management of diabetic nephropathy (general principles)

  • Management of diabetic nephropathy (smoking cessation)

  • Management of diabetic nephropathy (metformin)

  • Management of diabetic nephropathy (GLP-1 receptor agonists)

  • Management of diabetic nephropathy (SGLT-2 inhibitors)

  • Management of diabetic nephropathy (RAS inhibitors)

  • Management of diabetic nephropathy (mineralocorticoid receptor antagonists)

  • Management of diabetic nephropathy (laboratory follow-up)

  • Management of diabetic retinopathy

  • Management of diabetic neuropathy

  • Management of diabetic foot

  • Management of osteoporosis

  • Management of gastroparesis

Inpatient care

Management of hospitalized patients, general principles: as per ADA 2025 guidelines, ensure that institutions implement protocols using validated written or computerized provider order entry sets for the management of dysglycemia in the hospital allowing for a personalized approach.
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  • Management of hospitalized patients (HbA1C testing)

  • Management of hospitalized patients (glucose monitoring)

  • Management of hospitalized patients (insulin therapy)

  • Management of hospitalized patients (non-insulin therapy)

  • Management of hospitalized patients (treatment targets)

  • Management of hospitalized patients (prevention of hypoglycemia)

  • Management of hospitalized patients (oral carbohydrate fluids)

  • Management of hyperglycemic crises

Nonpharmacologic interventions

Smoking cessation: as per ADA 2025 guidelines, advise all patients with diabetes not to use cigarettes and other tobacco products or e-cigarettes.
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  • Weight loss

  • Physical activity

  • Dietary modifications (general principles)

  • Dietary modifications (eating patterns)

  • Dietary modifications (carbohydrates)

  • Dietary modifications (protein)

  • Dietary modifications (fat)

  • Dietary modifications (nonnutritive sweeteners)

  • Dietary modifications (sodium)

  • Dietary modifications (micronutrients and supplements)

  • Dietary modifications (alcohol)

  • Dietary modifications (religious fasting)

  • Psychosocial care

Perioperative care

Perioperative evaluation and management
As per ACC/ACS/AHA/…/SVM 2024 guidelines:
Obtain preoperative HbA1c testing in patients with or at risk for diabetes scheduled for elective noncardiac surgery if it has not been obtained in ≤ 3 months.
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Consider continuing metformin during the perioperative period in patients with diabetes or impaired glucose tolerance to maintain glycemic control.
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Surgical interventions

Bariatric surgery: as per ADA 2025 guidelines, consider offering metabolic surgery as a weight and glycemic management approach in patients with diabetes with BMI ≥ 30.0 kg/m² (or ≥ 27.5 kg/m² in Asian Americans) otherwise being good surgical candidates.
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Specific circumstances

Elderly patients, screening for comorbidities: as per ADA 2025 guidelines, assess the medical, psychological, functional (self-management abilities), and social domains in older adult patients with diabetes to provide a framework to determine goals and therapeutic approaches for diabetes management.
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  • Elderly patients (prevention of hypoglycemia)

  • Elderly patients (treatment goals)

  • Elderly patients (lifestyle modifications)

  • Elderly patients (pharmacotherapy)

  • Elderly patients (residing in nursing facilities)

  • Elderly patients (end-of-life care)

  • Pediatric patients (screening and diagnosis)

  • Pediatric patients (screening for hypertension)

  • Pediatric patients (screening for CVD)

  • Pediatric patients (screening for dyslipidemia)

  • Pediatric patients (screening for MASLD)

  • Pediatric patients (screening for nephropathy)

  • Pediatric patients (screening for retinopathy)

  • Pediatric patients (screening for neuropathy)

  • Pediatric patients (screening for obstructive sleep apnea)

  • Pediatric patients (screening for PCOS)

  • Pediatric patients (screening for psychosocial factors)

  • Pediatric patients (screening for substance use)

  • Pediatric patients (lifestyle modifications)

  • Pediatric patients (glycemic goals)

  • Pediatric patients (pharmacotherapy)

  • Pediatric patients (management of obesity)

  • Pediatric patients (management of hypertension)

  • Pediatric patients (management of dyslipidemia)

  • Pediatric patients (management of nephropathy)

  • Pediatric patients (transition to adult care)

  • Pregnant patients (screening)

  • Pregnant patients (preconception care)

  • Pregnant patients (nutrition)

  • Pregnant patients (glycemic targets)

  • Pregnant patients (management of gestational diabetes)

  • Pregnant patients (management of preexisting diabetes)

  • Pregnant patients (BP targets)

  • Pregnant patients (prevention of preeclampsia)

  • Pregnant patients (postpartum care)

  • Patients with CKD

  • Patients with AF

  • Patients with acute coronary syndrome (glycemic control)

  • Patients with acute coronary syndrome (revascularization)

  • Patients with acute coronary syndrome (antithrombotic therapy)

  • Patients with chronic coronary syndrome (pharmacotherapy)

  • Patients with chronic coronary syndrome (revascularization)

  • Patients with chronic coronary syndrome (antithrombotic therapy)

  • Patients with HF (general principles)

  • Patients with HF (asymptomatic)

  • Patients with HF (HFmrEF, HFpEF)

  • Patients with HF (HFrEF)

  • Patients with stroke

  • Patients with PAD

  • Patients with other vascular diseases

  • Patients with male hypogonadism

Patient education

Self-management education and support: as per ADA 2025 guidelines, advise all patients with diabetes to participate in developmentally and culturally appropriate diabetes self-management education and support to facilitate informed decision-making, self-care behaviors, problem-solving, and active collaboration with the healthcare team.
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Preventative measures

Primary prevention, lifestyle modifications: as per ADA 2025 guidelines, refer adult patients with overweight or obesity at high risk of T2DM, as seen in the Diabetes Prevention Program, to an intensive lifestyle behavior change program to achieve and maintain a weight reduction of at least 7% of initial body weight through healthy reduced-calorie diet and ≥ 150 minute/week of moderate-intensity physical activity.
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  • Primary prevention (vitamin D supplementation)

  • Primary prevention (metformin)

  • Routine immunizations

Follow-up and surveillance

Monitoring of glycemic status: as per ADA 2025 guidelines, assess glycemic status by HbA1c
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and/or appropriate continuous glucose monitoring metrics, such as time in range, time above range, and time below range. Consider obtaining fructosamine or continuous glucose monitoring for glycemic monitoring when an alternative to HbA1c is required.
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  • Continuous glucose monitoring

Quality improvement

Health promotion: as per ADA 2025 guidelines, ensure that treatment decisions are timely, rely on evidence-based guidelines, capture key elements within the social determinants of health, and are made collaboratively with patients or at risk for diabetes and caregivers based on individual preferences, prognoses, comorbidities, and informed financial considerations.
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  • Healthcare systems

  • Use of diabetes technology