Type 2 Diabetes Management

Key considerations: DKA or HHS, Undiagnosed Type 1 (autoimmune markers), Hypoglycemia from treatment

Cannot miss

history: Duration of diabetes, prior A1c values; Current medications and adherence; Hypoglycemic episodes; Complications: neuropathy, retinopathy, nephropathy, CVD; Diet, exercise, weight changes; exam: BMI, waist circumference; Foot exam (monofilament, pulses); Fundoscopic exam or referral; BP measurement; Skin exam (acanthosis nigricans, skin infections); labs: A1c (goal typically <7% for most adults); Fasting glucose; BMP (renal function); Lipid panel; Urine albumin-to-creatinine ratio (annual); TSH (if not recently checked); imaging: ; bedside: Fingerstick glucose

immediate: ; general: A1c goal <7% for most adults (individualize); Lifestyle: weight loss 5-10%, exercise 150 min/week, Mediterranean/DASH diet; Annual screening: retinal exam, foot exam, renal function, urine albumin; specific: diagnosis: New Diagnosis; steps: Metformin first-line (titrate to 1000mg BID); If A1c >9%: consider dual therapy or insulin from start; SGLT2 inhibitor or GLP-1 RA if ASCVD, HF, or CKD present; diagnosis: Not at Goal on Metformin; steps: Add SGLT2 inhibitor (empagliflozin, dapagliflozin) — especially if HF or CKD; Or GLP-1 RA (semaglutide, liraglutide) — especially if ASCVD or need weight loss; Or insulin if A1c very high; diagnosis: Insulin Initiation; steps: Basal insulin (glargine or detemir) 10 units or 0.1-0.2 U/kg at bedtime; Titrate by 2 units q3 days to fasting glucose <130; Continue metformin with insulin

admit: DKA or HHS; Severe hypoglycemia; New diagnosis with severe hyperglycemia and dehydration; discharge: Chronic management — follow-up in 3 months for A1c; consults: Endocrinology for complex or refractory cases; Diabetes education referral; Ophthalmology for annual retinal screening; Podiatry for high-risk feet

SGLT2 inhibitors and GLP-1 RAs reduce cardiovascular events and mortality independent of glucose lowering
Metformin is safe in CKD until eGFR <30 (updated FDA guidance)
A1c goal should be individualized: <7% for most, <8% for elderly or those with significant comorbidities
SGLT2 inhibitors reduce HF hospitalizations and slow CKD progression regardless of diabetes status