A new draft consensus report from the European Association for the Study of Diabetes (EASD) and the American Diabetes Association (ADA) updates the 2021 guidance on managing type 1 diabetes (T1D) in adults, with revisions to diagnostic criteria, recommendations on diabetes technology, and strategies for addressing obesity.
Anne L. Peters, MD, and Richard I.G. Holt, MD, co-chairs of the writing panel, presented an overview of the proposed draft at European Association for the Study of Diabetes (E ASD) 2025 Annual Meeting. The document was posted online and is open for feedback until 11:59 PM Eastern US time October 16, 2025.
“We want everybody to send comments, to get as large and wide input as we can, because this is about people and their lives,” Peters, professor of clinical medicine at Keck School of Medicine, University of Southern California, Los Angeles, told Medscape Medical News.
• ‘Reflecting Rapid Advances’ in T1D Management
The 2021 report, the first to focus specifically on T1D in adults, has been cited over 1000 times and has substantially influenced clinical practice, said Holt, professor in diabetes and endocrinology human development and health faculty of medicine at the University of Southampton, Southampton, England.
“Reflecting the rapid advances in the field, all sections have been updated to account for novel therapies, interventions to delay disease onset, and the integration of new technologies,” the draft authors wrote.
Three new sections — on
• screening for microvascular complications,
• cardiovascular (CV) risk management, and
• management of obesity — have been added, Hold noted.
• Other sections have been amalgamated and key points added.
• Diagnosis of T1D vs T2D in Adults
The section on diagnosis of T1D was the most challenging for the panel because the differences from T2D or monogenetic types often aren’t clear in adults, Peters told. “Kids are easy, adults are hard,” she noted.
• The newly proposed diagnostic algorithm advises consideration of T1D in adults younger than 35 years, with BMI < 25 or unintentional weight loss, diabetic ketoacidosis (DKA) or glucose > 20 mmol/L (360 mg/dL), rapid progression to insulin therapy, or just uncertainty about the diabetes type.
For any of these, the recommendation is to test at least one autoantibody, glutamic acid decarboxylase, followed by islet antigen 2 (IA-2) and zinc transporter 8 when needed and available.
• For individuals who are IAb negative or who have a single low titer of IAb positivity, consideration of C-peptide measurement is recommended. If < 200 pmol/L or 0.6 ng/mL, the diagnosis is T1D. However, a higher C-peptide level doesn’t necessarily exclude T1D, Holt said.
• Genetic testing for monogenetic diabetes should be considered for those younger than 35 years with C-peptide levels > 200 pmol/L, while those with C-peptide > 600 pmol/L who have typical features of T2D should be given that diagnosis unless they progress rapidly to insulin, in which case C-peptide testing should be repeated and T1D considered.
• In those for whom the diagnosis still isn’t clear, an initial trial of noninsulin therapy may be appropriate, with close supervision and repeat C-peptide measurement at a later time, Holt outlined.
• Call for Personalized T1D Care
Those with T1D who have glycemic levels in target range and acceptable well-being may need minimal intervention. Others, however, may have a variety of challenges including frequent low or high blood sugars, a desire to change treatment, diabetes distress, depression, eating disorder, or other psychological issues.
The report gives detailed information about insulin adjustment, device use, diet, exercise, and referral to mental health professionals. Diabetes self-management education and support (DSMES) is recommended for everyone with T1D. “We want to get providers to think about this really holistic way of looking at somebody who comes to clinic with their [T1D],” Peters said.
The use of DSMES is particularly helpful at critical times such as diagnosis, annually and/or when not meeting treatment targets, when complications develop, or when transitions in life or care occur, she said.
The section on nutrition emphasizes individualization based on the person’s preferences and needs and the impact of meal composition on glucose levels. The use of low or very-low carbohydrate diets may be acceptable as long as they are also part of healthy eating patterns. The use of technologies such as phone apps, bolus calculators, and artificial intelligence to evaluate meal composition are also covered.
Physical activity is encouraged unless contraindicated, with guidance around the effects of various types of exercise on glucose levels, with suggestions on how to use diabetes technology to optimize glucose levels around exercise.
The report also goes over other health-related behaviors including sleep, alcohol and drug use, and smoking cessation, along with preparing for travel, driving, and occupational support. A section devoted to psychosocial care advises screening for mental health and social determinants of health using validated questionnaires, and inclusion of a mental health professional in the care team.
• Technology Advised for All With T1D
“First and foremost, we are big believers that people with [T1D] should have real-time access to information about their glucose levels and trends, with warning alarms and alerts, which means we think everybody with T1D should have CGM [continuous glucose monitoring] available as the standard of care for glucose monitoring,” Peters said, adding that access to fingerstick monitoring is also necessary for the times when CGM isn’t available or isn’t functioning properly.
Recommended glucose targets for CGM haven’t changed since the last statement, she noted.
Automated insulin delivery systems (AIDs), comprising a CGM, pump, and algorithm connecting the two, are the preferred mode of insulin delivery in T1D due to improved glucose control, reduction in hypoglycemia, and improved quality of life. But if injections are used, they should be given as multiple daily injections of a basal insulin with premeal boluses using analog insulins. Inhaled insulin can be used for meal boluses.
There is insufficient evidence to recommend use of adjunctive therapies in T1D to improve glycemia, although such off-label use is increasing, said Peters. The risks and benefits of these should be discussed with each individual.
Patients should be assessed for hypoglycemic awareness using validated questionnaires, and use of CGM among the measures for prevention of severe hypoglycemia. The prevention of DKA includes DSMES, awareness of “sick day rules,” and ketone monitoring.
The report also covers new and evolving approaches to preservation and replacement of beta cell function, including disease-modifying immune therapies, and islet cell transplantation. Those topics, discussed in separate sections in the previous T1D guidance, have been merged into a single section because “the number of people who are now needing to have transplantation has gone down because the technology is now working so much better,” Holt told Medscape Medical News.
• Complications Screening: New Sections Added
Recommendations on screening for retinopathy, neuropathy, and kidney disease haven’t changed but weren’t included in the previous T1D guidance because they don’t differ significantly from those for T2D. But many people said they wanted that information in this guideline “so we listened,” Holt noted.
In some cases, the recommended frequency of such complications screening has been loosened, he said.
Similarly, CV risk management recommendations aren’t new and
• include a blood pressure target of < 120/80 mm Hg,
• statins for those aged 40 years or older or aged 20-39 at higher CV risk.
The report includes a detailed discussion about adjunctive use of GLP-1 receptor agonist (RA) and SGLT2 inhibitor drugs for CV risk management, separately from glycemic management.
• Obesity, Older People, Pregnancy: Individualizing Care
Holt pointed out that overweight and obesity are at least as common in T1D as in the general population, with additional contributors in T1D including increased food intake to combat hypoglycemia, and the effects of hyperinsulinemia. But the treatments are the same as for obesity overall, including behavioral interventions, pharmacotherapy including GLP-1 RAs, and bariatric surgery if indicated.
A section on older people with T1D emphasizes patient safety, particularly avoidance of hypoglycemia, as a key priority, with targets based on functional/cognitive status, available care partner support, history of hypoglycemia and hypoglycemia awareness, and life expectancy. Technology should not be discontinued or excluded due to older age alone. Simplification of insulin regimens should be considered if the current regimen becomes difficult.
“The good news is that all of us who’ve been in practice long enough are seeing our patients grow to be old, but as people age, there are all sorts of different requirements. I think it’s important that we’re all aware of this,” Peters said. “Remember, many of these people have had T1D for their whole lives, since they were children. You really want to work with them to do this in a way that is safe and effective and meets their own level of need.”
Pregnancy is addressed only briefly in this document because it is the subject of separate guidelines. But there is discussion of prepregnancy glycemic targets, referral to clinics with expertise in diabetic pregnancy management, and use of technology before, during, and after pregnancy.
In-hospital management guidance includes the importance of avoiding both hypoglycemia and DKA, and the use of technology. Noncritically ill patients using diabetes devices should be allowed to continue using them in the hospital when possible.
• Stronger Recommendations on SGLT2 Inhibitors Needed
During the discussion period, Thomas Danne, MD, Chief Medical Officer, International, of Breakthrough T1D, said that he would like to see stronger recommendations for use of adjunctive therapies, particularly SGLT2 inhibitors, in adults with T1D. “I think it’s important to state right now that SGLT2s can improve metabolic control and very likely reduce cardiovascular risk. People with T1D have the highest cardiovascular risk of all,” he told Medscape Medical News.
Danne also said he didn’t see enough about the system of care generally that needs to be in place to treat T1D. Discussing diagnosis was useful, he said, but we need a change in available care. “The biggest problem is we have only 30% of the American population with T1D on diabetes technology and AIDs are far behind.”
• Looking for Feedback
Peters said that the writing panel is looking specifically for feedback on the updated algorithm for diagnosing T1D in adults, and on the new sections on obesity, management of CV risk factors, and screening and detection of microvascular complications.
“We want you to tell us exactly what we’ve got right and wrong.”
From www.medscape.com
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