by IDS Director of Patient Care and Education, Alicia Downs
New 2025 ADA Recommendations That Could Impact Your Diabetes Management
-Knowing about changes to ADA recommendations can open up new treatment options for people with diabetes, just as insurance coverage trends close others.
We just got the 2025 American Diabetes Association (ADA) Guidelines for care. These are an important set of recommendations that the ADA makes each year that people with diabetes would be wise to keep their eye on.
Why? Because the vast majority of prescribers will do exactly what the ADA guidelines say, in the order they say them, and little else. This means that changes in guidelines can either open up, or close down options for treatment for people living with diabetes.
Here at IDS we are outside of the box thinkers, who see each client as an individual; we look at all the client’s needs and all the options and work with our clients to make the best recommendations for their situation. We take guidelines into consideration, but they are a piece of a larger puzzle.
How we work at IDS is NOT THE NORM!
Most prescribers will simply line up the patient’s clinical indicators (A1C, lipid levels, BMI, Age, etc), feed these into the guidelines and follow the recommendations like a flow chart.
More restrictive is that payers will often require patients to follow the flowchart of the guidelines to get therapies covered. For example, a patient with type 2 diabetes may be required to try medications that simply will not work well for them, in order to PROVE failure so that they can access medications that are further along the Guideline’s recommended order of medication prescribing. But knowing that this is the issue the patient can work with their prescriber to either pull documentation of a medication failure from a previous use, or they can find other reasons to skip the medication (Side effects, risk of weight gain, etc) or at least shorten the time the medication will be tried to reduce the loss of clinical inertia and keep treatment efforts moving along.
But this year we have one exciting guideline change that has the potential to really blow the doors off options for medication therapy for people with insulin-dependent diabetes.
We have seen GLP1 receptor agonist (Glp1) medications take the pharmaceutical world by storm over the last few years. Now approved to treat everything from Obstructive Sleep apnea to reducing the risk of Heart attacks and stroke, these medications are really taking off! However, we have seen them most prevalently used for treatment of type 2 diabetes and weight loss. They have proven very effective for both. But until now they remained out of reach of people with type 1 diabetes, even though they carry a lot of benefits. (You can read up on those benefits here: Ozemipic’s new indication, what does it mean for type 1 diabetes management?)
However, because none of these medications carry an indication for Type 1 diabetes insurance would not cover it unless the patient also could get a diagnosis for an indicated diagnosis, the most common being obesity. This coverage was tough to get for some patients, but 2025 is showing a sweeping move in Insurance carriers forming a lock-step profit protection phalanx!
Multiple major insurance carriers announced in the last month that they will no longer be covering GLP1 medications for weight loss! Some insurance carriers have stopped covering weight loss medications entirely! (This is an absolutely outrageous overstepping of patient rights and a restriction of clinical decision-making that is beyond egregious! Obesity is the fastest-growing and most life-threatening health epidemic the United States has ever seen and this kind of blanket policy serves no purpose but lining the pockets of insurance companies at the loss of important clinical tools to their customers! But this is an article on diabetes management so I’m going to try to stay focused and not rant too much) This lockout of obesity as a diagnosis will leave a LOT of people struggling to cope. But one important guideline change in the 2025 Standards of Care throws the door for GLP1 access wide open for those of us diagnosed with a form of diabetes other than type 2.
DUAL DIAGNOSIS!
The 2025 Standards of Care in Diabetes includes a very important passage in page S30:
“A diagnosis of Type 1 diabetes does not preclude having features classically associated with Type 2 diabetes (e.g., insulin resistance, obesity, and other metabolic abnormalities), and until more precise subsets are used in clinical practice, it may be appropriate to categorize such an individual as having features of both type 1 and type 2 diabetes to facilitate access to appropriate treatment(e.g., glucagon-like peptide 1 receptor agonist or sodium-glucose cotransporter 2 inhibitor therapies for potential weight and other cardiometabolic benefits) and monitoring systems.”
You heard right! The ADA Guidelines now specifically recommend Dual diagnosis for persons with non-Type 2 diagnosed diabetes to also be assessed for DUAL DIAGNOSIS of both Types 1 and 2 diabetes (And one can easily expand this to include type 3C, Genetic and other forms of diabetes as well) Specifically to open the doors for approval of therapies NOT indicated for the treatment of type 1 diabetes!
THIS IS HUGE!
While Insurance payers have eliminated one small door to access to “Off label” medications for people with type 1 diabetes, the ADA has blown the doors off access entirely by making dual diagnosis not only possible, but a Guideline Standard of Care!
So how can someone with type 1 get a type 2 dual diagnosis? Here are some qualifiers that can be documented to support a type 2 diagnosis:
- Insulin resistance: By the textbook, anyone using more than 0.5 units of insulin per KG may be said to be showing signs of insulin resistance.
- Elevated BMI: especially with a high hip-to-waist ratio, both are indicative of metabolic syndrome a “metabolic abnormality” associated with type 2 diabetes.
- Elevated triglycerides: Elevated lipid levels and high triglycerides, particularly those resistant to dietary changes are another common metabolic abnormality associated with type 2 diabetes.
- Other diagnoses often associated with Type 2 diabetes: such as severe obesity, acanthosis nigricans, metabolic dysfunction–associated steatotic liver disease(formerly called Non-Alcoholic Fatty Liver Disease), Heart disease, gestational diabetes, periodontal disease, and neuropathy.
- Family History of type 2 diabetes and/or high-risk racial-ethnic heritage
- History of High dose steroid use, antipsychotic medication use, statins, some HIV medications
Any documentation of the above-listed issues and certainly any 2 or more in combination can be sufficient to diagnose secondary Type 2 diabetes in someone with a primary insulin-dependent diabetes diagnosis.
This dual diagnosis then allows prescribers to write prescriptions for medications used to treat type 1 diabetes for this large cross-section of the non-type 2 population with diabetes. The prescriber should list type 2 diabetes as the diagnosis code. For the vast majority of pharmacy transactions that are done entirely by computer, this will result in approved coverage. (though formulary tier coverage still needs to be taken into consideration to keep costs down) Should the dual diagnosis be caught in an audit or red-flagged by the insurance system (Until now we have had to worry about our type 1 medications and technologies being denied because we carried a dual or previous type 2 diabetes diagnosis) all the patient and prescriber need do is site S30 of the 2025 ADA Standards of care in Diabetes and the insurance company will have little choice but to comply.
Finally, the guidelines that have restricted our care for so long are now a tool we can use to greatly expand our coverage for care!
Hopefully, this bit of good news can take the sting out of going to the pharmacy for some of our diabetes community (while we wait for the pain and hemorrhaging of funds that is annual deductible rollover to subside)
For education and guidance on adding (previously) off-label prescribing to your regimen or for help getting your management needs met, call to schedule an appointment with the outside-the-box thinking clinicians of Integrated Diabetes Services!
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