AttendMe Owl Logo
AttendMe
Sign In
All Pathways
Family MedicineManagement

Type 2 Diabetes: Initial Workup and Glucose-Lowering Management (ADA 2026 / ADS 2026)

Type 2 Diabetes: Initial Workup and Glucose-Lowering Management (ADA 2026 / ADS 2026): New Type 2 Diabetes in an Adult → Red Flags: Catabolic, Ketotic o...

Pathway Overview

14 steps

Algorithm Steps

14 total

  1. 01Start

    New Type 2 Diabetes in an Adult

    Diagnosis: HbA1c ≥6.5% (48 mmol/mol), fasting glucose ≥7.0 mmol/L or 2-h OGTT glucose ≥11.1 mmol/L. Without clear symptoms, confirm with a second abnormal result. Symptoms plus random glucose ≥11.1 mmol/L also diagnose diabetes.

  2. 02Warning

    Red Flags: Catabolic, Ketotic or Glucose ≥16.7 mmol/L - Insulin First

    Weight loss, polyuria or polydipsia, ketones, HbA1c >10% (86 mmol/mol) or glucose ≥16.7 mmol/L: assess today. Do not rely on metformin alone with a 3-month review.

    • Unwell, vomiting, dehydrated, drowsy or ketones raised: ED now for DKA or HHS
    • Well: start insulin with diabetes team advice (adult basal 10 units/day or 0.1-0.2 units/kg/day)
    • Young, lean or ketotic: test islet antibodies (possible type 1 diabetes or LADA); do not start SGLT2i
  3. 03Action

    Initial Evaluation (All Patients)

    Baseline tests guide drug choice and doses.

    • eGFR, creatinine, electrolytes: needed before metformin or SGLT2i
    • Urine albumin:creatinine ratio (ACR). CKD = eGFR <60 or ACR ≥3 mg/mmol, confirmed on repeat
    • HbA1c, fasting lipids, LFT with FIB-4
    • History: ASCVD, heart failure, hypoglycaemia risk, pregnancy plans; BP, weight
    • Eye exam (dilated or retinal photography) at diagnosis
    • Foot exam: skin, deformity, 10-g monofilament, pulses
  4. 04Action

    Lifestyle, Education and HbA1c Target (All)

    Start at diagnosis, alongside any drug. HbA1c target usually ≤7.0% (53 mmol/mol); individualise.

    • Diabetes self-management education (diabetes educator) and dietitian
    • 150 min or more per week of moderate activity, over at least 3 days
    • Overweight: aim for at least 5-7% weight loss; ≥10% may allow fewer glucose drugs
    • Stop smoking and vaping
    • Lower target (<6.5%, 48 mmol/mol) if safe; less strict if frail or high hypoglycaemia risk
  5. 05Action

    Heart, Kidney, Eye and Foot Care (All)

    At diagnosis and at least once a year. If pregnancy is possible: discuss contraception before an ACE inhibitor, ARB or statin.

    • BP goal <130/80 mmHg if safe
    • Statin: ADA advises for most aged 40-75. Australia: assess risk with AusCVDRisk (age 35-79)
    • Albuminuria with hypertension: ACE inhibitor or ARB (check potassium and creatinine; not in pregnancy)
    • eGFR and ACR at least yearly (1-4 times a year if CKD)
    • Foot exam at least yearly; eye exam yearly, or every 1-2 years if no retinopathy and at target
  6. 06Warning

    Before Any Drug: Kidney Function, Ketone Risk, Pregnancy

    Before each new drug check eGFR, ketosis risk and pregnancy plans. Prior pancreatitis, or personal or family history of medullary thyroid cancer or MEN2: avoid GLP-1 RA and tirzepatide.

    • Metformin: not if eGFR <30 or severe liver disease; eGFR 30-44 half dose; stop in AKI, dehydration or severe illness
    • SGLT2i: ketoacidosis can occur with near-normal glucose. Stop when unwell or fasting; omit ≥3 days before surgery with a hospital stay
    • Pregnant or planning pregnancy: stop GLP-1 RA, SGLT2i, ACE inhibitor or ARB, and statin; get specialist advice
  7. 07Action

    Start Metformin (Most Adults)

    Adults: usual first drug unless contraindicated or not tolerated. ASCVD, HF or CKD: also add SGLT2i or GLP-1 RA (next step).

    • Adult: metformin 500 mg once or twice daily with meals
    • Increase over a few weeks as tolerated; 500 mg three times daily is often enough; max 1 g three times daily
    • eGFR 30-44: half dose; eGFR <30: do not use
    • Hold for iodinated contrast if eGFR <30, AKI or unwell; recheck eGFR before restart
    • GI upset: slower titration, take with food, or extended-release form
    • Long-term use: check vitamin B12
  8. 08Decision

    ASCVD, Heart Failure, CKD or High CV Risk?

    Yes: add a drug with heart or kidney benefit now, whatever the HbA1c.

    • Established ASCVD (MI, stroke, PAD, revascularisation)
    • Heart failure (reduced or preserved EF)
    • CKD: eGFR <60 or ACR ≥3 mg/mmol
    • High CV risk: e.g. age ≥55 with 2 or more risk factors
  9. If Yes
    1. 09Action

      Yes - ASCVD, HF or CKD: Add SGLT2i or GLP-1 RA Now

      Give irrespective of HbA1c, with metformin if eGFR ≥30. GLP-1 RA: avoid if prior pancreatitis.

      • Heart failure: SGLT2i (empagliflozin or dapagliflozin)
      • CKD: SGLT2i (start if eGFR ≥20 empagliflozin, ≥25 dapagliflozin) or GLP-1 RA with kidney benefit (semaglutide)
      • ASCVD or high CV risk: GLP-1 RA (semaglutide, dulaglutide, liraglutide) or SGLT2i with proven CV benefit
      • eGFR <30: GLP-1 RA preferred for glucose lowering (Australia: not PBS-subsidised alone)
      • SGLT2i: genital hygiene; watch volume depletion with diuretics
      • GLP-1 RA: known retinopathy, monitor eyes; before procedures, 24 h clear fluids (do not stop routinely)
      • Australia PBS: GLP-1 RA if SGLT2i fails or is not tolerated; GLP-1 RA with SGLT2i only if SGLT2i is for HF or CKD
    2. 10Decision

      HbA1c at 3 Months: At Target?

      Target usually ≤7.0% (53 mmol/mol); lower if safe, less strict if frail or high hypoglycaemia risk.

      • Check adherence, side effects and hypoglycaemia first
      • Reassess every 3-6 months until at target
    3. If Yes
      1. At target
      2. 11Outcome

        Yes - At Target: Continue and Review

        Continue. HbA1c at least every 6 months (every 3 months if treatment changes). Hypoglycaemia or frailty: reduce sulfonylurea or insulin. Repeat yearly heart, kidney, eye and foot care.

      If No
      1. Above target
      2. 12Action

        No - Above Target: Intensify Without Delay

        Add a drug and review in 3 months. Keep an SGLT2i or GLP-1 RA given for HF, CKD or ASCVD, even if HbA1c falls little. Pioglitazone: not in heart failure.

        • ASCVD, HF or CKD: add the other class (SGLT2i with GLP-1 RA), or DPP-4i (not saxagliptin in HF), sulfonylurea or insulin
        • No ASCVD, HF or CKD: add SGLT2i, GLP-1 RA or tirzepatide, DPP-4i, sulfonylurea or pioglitazone by weight, hypoglycaemia risk and cost
        • Sulfonylurea: not preferred as first add-on (hypoglycaemia). Adding any drug: review sulfonylurea or insulin dose
        • Do not combine a DPP-4i with a GLP-1 RA or tirzepatide
        • Other drugs that did not lower HbA1c by ≥0.5% after 3 months: review and consider stopping
        • Australia PBS: GLP-1 RA with SGLT2i only if the SGLT2i is for HF or CKD
        • Complex or not at target on 3 drugs: seek endocrinology advice
      3. 13Action

        Still Above Target on Combination: Add Basal Insulin

        Consider a GLP-1 RA first if not on one. Starting insulin: reduce or stop sulfonylurea.

        • Adult: start basal insulin 10 units/day or 0.1-0.2 units/kg/day
        • Increase by 2 units every 3 days until fasting glucose is at target (often 4.4-7.2 mmol/L; individualise), without hypoglycaemia
        • Hypoglycaemia with no clear cause: lower dose by 10-20%
        • Continue metformin, SGLT2i and GLP-1 RA unless contraindicated
        • Teach hypoglycaemia treatment; prescribe glucagon; consider CGM
        • HbA1c above target with fasting glucose at target, overnight fall ≥2.8 mmol/L or hypoglycaemia: stop titrating; add GLP-1 RA or mealtime insulin
      4. Path rejoins step 10Shared downstream outcome
    If No
    1. 14Action

      No - No ASCVD, HF or CKD: Choose by Glucose and Weight Goals

      Metformin plus lifestyle first. HbA1c ≥1.5% above target: consider a second drug from the start.

      • Weight a main goal: GLP-1 RA (semaglutide) or tirzepatide give most weight loss
      • Other options: SGLT2i, DPP-4i, sulfonylurea, pioglitazone, by hypoglycaemia risk and cost
      • Australia: tirzepatide not PBS-subsidised; SGLT2i and GLP-1 RA are PBS-listed as add-on, not first drug alone
      • Prioritise drugs with low hypoglycaemia risk if at high risk
    2. Path rejoins step 10Shared downstream outcome

Guideline Source

ADA Standards of Care in Diabetes—2026, Section 9 Pharmacologic Approaches to Glycemic Treatment (Australia: ADS Australian Type 2 Diabetes Glycaemic Management Algorithm, September 2026)

DOI: 10.2337/dc26-S009View Guideline

Clinical Safety Information

Clinical Decision Support — Not a Substitute for Clinical Judgment

Individual patient factors may require deviation from these recommendations.

Known Limitations

  • Adults with type 2 diabetes only: not for type 1 diabetes, LADA, pregnancy, gestational diabetes or children
  • Adult starting doses only: check product information for kidney and liver dosing
  • Does not cover hyperglycaemic emergencies (DKA, HHS), inpatient or perioperative glucose management
  • Obesity pharmacotherapy and metabolic surgery are not covered in detail

Contraindicated Populations

pediatricpregnancytype1_diabetes

Applicable Regions

AUUSEU

AU: ADS algorithm (Sept 2026): metformin is the usual first drug; add an SGLT2i (or GLP-1 RA if SGLT2i not tolerated) in CVD, multiple CV risk factors or kidney disease. PBS: GLP-1 RA only if SGLT2i fails or is not tolerated, and with an SGLT2i only when the SGLT2i is prescribed for HF or CKD; tirzepatide is not PBS-subsidised. Australian metformin PIs list creatinine clearance <60 mL/min as a contraindication; ADS, KHA and KDIGO support use down to eGFR 30 with dose reduction.

EU: Based on ADA Standards of Care 2026; check national formulary and reimbursement rules.

US: Based on ADA Standards of Care in Diabetes 2026 (Sections 2, 4, 6, 9-12).

Version 2Next review: 2027-01-31

Related Family Medicine Pathways

Acute Low Back Pain Evaluation & Management (ACP 2017)

Diagnostic

Adult Headache Evaluation & Management (Primary Care)

Diagnostic

Adult Obesity Evaluation & Management (ADS 2026)

Management

Age-Based Preventive Care Screening (USPSTF Grade A/B)

Diagnostic

Next steps

Finish the workflow by opening the most relevant calculator, then convert the session into a live account when you are ready.

Calculator

Body Mass Index

Weight classification based on height and weight

Open page

Compare

AttendMe.ai vs ChatGPT

See how this pathway workflow compares against ChatGPT.

Open page

Commercial

Start free

Run the pathway in a live AttendMe account with citations and tracked usage.

Start free

Related Resources

All Clinical PathwaysClinical CalculatorsAI Chat with Auto-Detection

Frequently Asked Questions

What is the Type 2 Diabetes: Initial Workup and Glucose-Lowering Management (ADA 2026 / ADS 2026)?

The Type 2 Diabetes: Initial Workup and Glucose-Lowering Management (ADA 2026 / ADS 2026) is a management clinical algorithm for Family Medicine. It provides a structured decision tree to guide clinical decision-making, based on ADA Standards of Care in Diabetes—2026, Section 9 Pharmacologic Approaches to Glycemic Treatment (Australia: ADS Australian Type 2 Diabetes Glycaemic Management Algorithm, September 2026).

What guideline is the Type 2 Diabetes: Initial Workup and Glucose-Lowering Management (ADA 2026 / ADS 2026) based on?

This algorithm is based on ADA Standards of Care in Diabetes—2026, Section 9 Pharmacologic Approaches to Glycemic Treatment (Australia: ADS Australian Type 2 Diabetes Glycaemic Management Algorithm, September 2026) (DOI: 10.2337/dc26-S009).

What are the limitations of the Type 2 Diabetes: Initial Workup and Glucose-Lowering Management (ADA 2026 / ADS 2026)?

Known limitations include: Adults with type 2 diabetes only: not for type 1 diabetes, LADA, pregnancy, gestational diabetes or children; Adult starting doses only: check product information for kidney and liver dosing; Does not cover hyperglycaemic emergencies (DKA, HHS), inpatient or perioperative glucose management; Obesity pharmacotherapy and metabolic surgery are not covered in detail. Individual patient factors may require deviation from these recommendations.

Get AI-Powered Analysis Alongside This Algorithm

In AttendMe.ai, the Type 2 Diabetes: Initial Workup and Glucose-Lowering Management (ADA 2026 / ADS 2026) appears automatically when your clinical question matches — alongside evidence from 3M+ peer-reviewed articles.

Try AttendMe Free