• Diagnosis of diabetes: HbA1c ≥ 6.5% (48 mmol/mol) on two occasions (or once with classic symptoms/hyperglycemia).
• Prediabetes: HbA1c 5.7-6.4% - lifestyle intervention is the initial step, not pharmacotherapy.
• Starting pharmacologic therapy once diagnosed (per ADA-type guidance):
  • HbA1c at diagnosis < 7.5-8%: Start with lifestyle modification +/- metformin monotherapy.
  • HbA1c ≥ 8.5-9% (or markedly symptomatic): Consider starting dual therapy (metformin + a second agent) at diagnosis, since monotherapy is unlikely to reach target.
  • HbA1c ≥ 10%, blood glucose ≥ 300 mg/dL, or significant symptoms (polyuria, polydipsia, weight loss, ketosis): Consider starting insulin (with or without other agents) rather than oral agents alone.
• General individualized target once on treatment: HbA1c < 7% for most non-pregnant adults; less stringent (< 7.5-8%) for older adults or those with comorbidities/limited life expectancy; more stringent (< 6.5%) may be reasonable early in disease with no significant hypoglycemia risk.

ADA Standards of Care in Diabetes - 2026

• HbA1c targets remain individualized: < 7% for most nonpregnant adults, with less stringent goals (< 7.5-8%) for those with limited life expectancy or high hypoglycemia risk, and tighter goals (< 6.5%) reasonable early in disease if achievable safely.
• New perioperative target: for the first time, a specific A1C goal of ≤ 8% before surgery, with glucose 100-180 mg/dL peri-operatively.
• Broader/earlier technology use: CGM and automated insulin delivery (AID) are now recommended soon after diagnosis for both type 1 and type 2 diabetes, with fewer eligibility restrictions. CGM is also now recommended at diabetes onset for anyone on insulin, on non-insulin agents that can cause hypoglycemia, or where CGM would help management.
• GLP-1/dual GIP-GLP-1 agents now recommended for type 2 diabetes with symptomatic HFpEF, MASLD/MASH, obesity, or CKD - irrespective of HbA1c level. For the first time, GLP-1 receptor agonists are also supported for people with type 1 diabetes.
• Blood pressure: goal < 130/80 mmHg for most adults; for older adults, < 130/80 if safely achievable, otherwise < 140/90 for those with poor health or limited life expectancy.
• Kidney protection: simultaneous initiation of an SGLT2 inhibitor plus a nonsteroidal MRA can now be considered (in addition to a RAS blocker) in adults with uACR ≥ 100 mg/g and eGFR 30-90.
• A new insulin titration algorithm for type 1 diabetes was added, and medication/insulin cost tables were updated (as of July 2025 pricing).

AACE Algorithm for Management of Adults with Type 2 Diabetes - 2026 Update

1. 10 core principles for managing adults with type 2 diabetes
2. Prediabetes algorithm - lifestyle, weight management, and pharmacologic/nonpharmacologic weight-loss interventions to prevent progression
3. A new diabetes classification algorithm - encourages clinicians to consider atypical/alternative forms of diabetes rather than assuming standard type 1/type 2
4. Cardiovascular risk, dyslipidemia, and hypertension management
5. A comorbidity/complication-centric approach (prioritizing agents with cardiorenal, hepatic, or weight benefits) versus a glucose-centric algorithm for initial/add-on therapy when major comorbidities are absent
6. Insulin initiation and titration algorithm, emphasizing individualized targets and CGM use
7. Updated pharmacotherapy profiles for both diabetes and obesity medications (efficacy, benefits, adverse effects)
8. Updated immunization guidance aligned with current ACIP recommendations

• Both now favor early combination therapy or comorbidity-driven agent selection over strict "metformin first, escalate by HbA1c" sequencing.
• Both endorse GLP-1/GIP-GLP-1 agents and SGLT2 inhibitors independent of HbA1c when compelling comorbidities (obesity, HFpEF, CKD, MASLD/MASH) are present.
• Insulin is still reserved for very high HbA1c (≥ 10%), marked symptoms/ketosis, or glucose ≥ 300 mg/dL at presentation.