Type 2 Diabetes Initial Workup & Management (ADA 2025)

Algorithm Steps

1. ▶

   Start

   New Diagnosis Type 2 Diabetes

   Confirmed by A1c ≥6.5%, FPG ≥126, or 2h-OGTT ≥200

   1. ●

      Action

      Initial Evaluation

      Comprehensive metabolic assessment

      • A1c (confirms diagnosis, baseline)
      • Lipid panel (CV risk)
      • Comprehensive metabolic panel
      • Urinalysis + urine albumin/creatinine
      • Foot exam, fundoscopy referral
      1. ◆

         Decision

         Cardiovascular/Renal Risk Assessment

         Determines medication priority

         • Established ASCVD?
         • Heart failure present?
         • CKD (eGFR <60 or albuminuria)?
         • Multiple CV risk factors?
         1. ●

            Action

            High CV/Renal Risk

            GLP-1 RA or SGLT2i priority

            • Add GLP-1 RA (semaglutide, liraglutide) for ASCVD
            • Add SGLT2i (empagliflozin, dapagliflozin) for HF/CKD
            • Independent of A1c, add to metformin
            • Both classes have proven CV/renal benefits
            1. ◆

               Decision

               A1c Recheck at 3 Months

               Assess response to therapy

               • Target: <7% for most adults
               • <6.5% if young, no hypoglycemia risk
               • <8% if elderly, frail, limited life expectancy
               1. ✓

                  Outcome

                  At A1c Goal

                  Continue current regimen, monitor every 3-6 months

               2. ●

                  Action

                  Add Second Agent

                  Intensify therapy if above goal

                  • Preferred: GLP-1 RA or SGLT2i
                  • Alternatives: DPP-4i, TZD, sulfonylurea
                  • Consider cost, side effects, patient preference
                  • Avoid SU + insulin (hypoglycemia risk)
               3. ●

                  Action

                  Add Third Agent or Insulin

                  Triple therapy or basal insulin

                  • If still above goal on 2 agents
                  • Consider basal insulin (start 10U or 0.1-0.2 U/kg)
                  • Titrate by 2U every 3 days to FPG goal
                  • Can add to GLP-1 RA + metformin
         2. ●

            Action

            Low CV Risk

            Focus on glycemic control

            • Start metformin 500mg BID
            • Titrate to 1000mg BID over 1-2 months
            • If A1c >9%, consider dual therapy upfront
            • Lifestyle modification essential
      2. ●

         Action

         Complication Screening

         Annual assessments

         • Dilated eye exam annually
         • Foot exam each visit
         • BP goal <130/80
         • Statin for ages 40-75
         • UACR annually
      3. ●

         Action

         Lifestyle Interventions

         Foundation of all therapy

         • Medical nutrition therapy referral
         • 150 min/week moderate activity
         • Weight loss goal 5-10%
         • Smoking cessation
         • Diabetes self-management education