Type 2 Diabetes Management (ADA 2025)

Algorithm Steps

1. ▶

   Start

   T2DM Diagnosis Confirmed

   A1c ≥6.5%, FPG ≥126, or 2hr PG ≥200

   1. ●

      Action

      Lifestyle Management (All Patients)

      Foundation of diabetes care

      • Medical nutrition therapy
      • Weight management (if overweight/obese)
      • Physical activity: 150+ min/week moderate
      • Diabetes self-management education
      • Smoking cessation
      1. ◆

         Decision

         Assess CV/Renal Risk

         Key determinant of agent selection

         • Established ASCVD?
         • Heart failure (HFrEF or HFpEF)?
         • CKD (eGFR <60 or UACR >30)?
         • High CV risk factors?
         1. ●

            Action

            ASCVD, HF, or CKD Present

            Select agent with proven benefit

            • GLP-1 RA with CV benefit (ASCVD)
            • SGLT2i (HF or CKD preferred)
            • Can use BOTH for additive benefit
            • Add metformin if tolerated
            1. ●

               Action

               GLP-1 RA or SGLT2i Selection

               For cardiorenal protection

               • GLP-1 RA: semaglutide, dulaglutide, liraglutide
               • SGLT2i: empagliflozin, dapagliflozin, canagliflozin
               • HF: prefer SGLT2i
               • ASCVD: either or both
               1. ◆

                  Decision

                  Reassess A1c at 3 Months

                  Target individualized (usually <7%)

                  • <7% for most adults
                  • <6.5% if low hypoglycemia risk
                  • <8% if limited life expectancy, complications
                  1. ✓

                     Outcome

                     At A1c Goal

                     Continue current regimen, monitor q3-6 months

                  2. ●

                     Action

                     Intensify Therapy

                     Add additional agent

                     • Add GLP-1 RA if not on one
                     • Add SGLT2i if not on one
                     • Consider tirzepatide (dual agonist)
                     • Add basal insulin if A1c still high
                     1. ●

                        Action

                        Basal Insulin Indication

                        When oral/injectable agents insufficient

                        • A1c >10% or glucose >300 at diagnosis
                        • Symptomatic hyperglycemia
                        • Catabolic features
                        • Start 10 units or 0.1-0.2 U/kg/day
                        • Titrate by 2 units q3 days to FBG goal
                     2. ⚠

                        Warning

                        Minimize Hypoglycemia Risk

                        Avoid sulfonylureas as first intensification

                        • SU: weight gain + hypoglycemia risk
                        • Prefer GLP-1 RA or SGLT2i instead
                        • If cost barrier: metformin + SU acceptable
         2. ◆

            Decision

            No ASCVD/HF/CKD

            A1c and weight considerations

            • If A1c <1.5% above target: monotherapy
            • If A1c ≥1.5% above target: consider dual
            • Consider weight management goals
            1. ●

               Action

               Metformin First-Line

               Unless contraindicated or not tolerated

               • Start 500mg daily with food
               • Titrate to 1500-2000mg/day
               • Hold if eGFR <30
               • Monitor B12 with long-term use
            2. ●

               Action

               Weight Management Priority

               If weight loss is primary goal

               • GLP-1 RA (high efficacy): semaglutide, tirzepatide
               • GIP/GLP-1 RA: tirzepatide
               • Or GLP-1 RA + SGLT2i combination