What are the prescription templates for type 2 diabetes mellitus (T2DM) management and treatment, including all case scenarios?

Type 2 Diabetes Mellitus Prescription Templates

Initial Therapy: Newly Diagnosed T2DM

Start metformin 500-850 mg once or twice daily with meals alongside comprehensive lifestyle modifications (150 minutes/week moderate-intensity exercise, 7% weight loss goal) as first-line therapy for all newly diagnosed patients without contraindications. 1, 2

Prescription Template - Initial Therapy

Metformin 500 mg PO
Sig: Take 1 tablet twice daily with breakfast and dinner
Disp: 60 tablets
Refills: 3

Instructions:
- Titrate to 850-1000 mg twice daily over 2-4 weeks as tolerated
- Target HbA1c: 7-8% in most adults
- Check HbA1c every 3 months until target reached

Common pitfall: Do not delay metformin initiation while attempting lifestyle modifications alone—start both simultaneously at diagnosis. 2

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Second-Line Therapy: Inadequate Control on Metformin

Add an SGLT-2 inhibitor or GLP-1 receptor agonist to metformin when HbA1c remains above target after 3 months at maximum tolerated metformin dose. 2, 3

Decision Algorithm for SGLT-2i vs GLP-1 RA:

Choose SGLT-2 inhibitor if:

• Heart failure present or high risk 1
• Chronic kidney disease (reduces progression 24-39%) 2
• Need to reduce heart failure hospitalization 3

Choose GLP-1 receptor agonist if:

• High stroke risk 2, 3
• Need maximum weight loss (>10% possible with high-potency agents) 4
• Cardiovascular disease present 1

Prescription Template - SGLT-2 Inhibitor (Empagliflozin)

Empagliflozin 10 mg PO
Sig: Take 1 tablet once daily in the morning
Disp: 30 tablets
Refills: 3

Instructions:
- May increase to 25 mg daily after 4 weeks if tolerated
- Monitor for genital mycotic infections
- Ensure adequate hydration
- Continue metformin at current dose

Prescription Template - GLP-1 Receptor Agonist (Semaglutide)

Semaglutide 0.25 mg subcutaneous injection
Sig: Inject 0.25 mg once weekly for 4 weeks, then increase to 0.5 mg weekly
Disp: 4 pre-filled pens (0.25 mg)
Refills: 0

Instructions:
- Titration schedule: 0.25 mg weekly x 4 weeks → 0.5 mg weekly x 4 weeks → 1 mg weekly (maintenance)
- Can increase to 2 mg weekly if needed for glycemic control
- Inject subcutaneously in abdomen, thigh, or upper arm
- Continue metformin at current dose

Critical action: When adding SGLT-2i or GLP-1 RA, reduce or discontinue sulfonylureas or long-acting insulin to prevent hypoglycemia. 3

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Triple Therapy: Persistent Inadequate Control

If HbA1c remains above target on metformin plus either SGLT-2i or GLP-1 RA, add the other class to create triple combination therapy (metformin + SGLT-2i + GLP-1 RA). 5

Prescription Template - Triple Combination

Continue:
- Metformin 1000 mg PO twice daily
- Empagliflozin 25 mg PO once daily

Add:
Liraglutide 0.6 mg subcutaneous injection
Sig: Inject 0.6 mg once daily for 1 week, then increase to 1.2 mg daily
Disp: 2 pre-filled pens (0.6 mg)
Refills: 0

Instructions:
- Titration: 0.6 mg daily x 1 week → 1.2 mg daily x 1 week → 1.8 mg daily (if needed)
- Inject at same time each day, any time
- Monitor blood glucose if experiencing symptoms

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Immediate Insulin Therapy: Severe Hyperglycemia

Start insulin therapy immediately without delay if any of the following are present: ketosis/DKA, random blood glucose ≥250 mg/dL, or HbA1c ≥8.5%. 2

Prescription Template - Basal Insulin Initiation

Insulin glargine U-100
Sig: Inject 10 units subcutaneously once daily at bedtime
Disp: 1 vial (10 mL) or 5 pens
Refills: 3

Starting dose calculation: 0.5 units/kg/day
Example: 70 kg patient = 35 units/day total
- Start with 10 units basal insulin at bedtime
- Titrate by 2 units every 3 days based on fasting glucose
- Target fasting glucose: 80-130 mg/dL

Supplies needed:
- Blood glucose meter and test strips
- Insulin syringes or pen needles
- Lancets

Instructions:
- Check fasting blood glucose daily
- Adjust dose every 2-3 days until target reached
- Continue metformin at current dose

Prescription Template - Basal-Bolus Insulin (if basal alone insufficient)

Insulin glargine U-100
Sig: Inject 20 units subcutaneously once daily at bedtime
Disp: 1 vial or 5 pens
Refills: 3

Insulin lispro U-100
Sig: Inject 5 units subcutaneously before each meal (3 times daily)
Disp: 1 vial or 5 pens
Refills: 3

Instructions:
- Total daily dose: 0.5 units/kg/day divided as 50% basal, 50% bolus
- Bolus dose divided equally before breakfast, lunch, dinner
- Adjust basal based on fasting glucose
- Adjust bolus based on pre-meal and 2-hour post-meal glucose
- Check blood glucose before meals and at bedtime

Critical consideration: If insulin deficiency is predominant at diagnosis (severe hyperglycemia, weight loss, ketosis), reverse the medication order: insulin first, then add cardio-renal protective medications (SGLT-2i, GLP-1 RA) once stabilized. 5

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Cardiovascular Risk Reduction: High-Risk Patients

For patients with established cardiovascular disease, chronic kidney disease, or very high cardiovascular risk, add SGLT-2 inhibitor or GLP-1 receptor agonist regardless of HbA1c level. 1, 2

Prescription Template - CV Risk Reduction (with CVD)

Empagliflozin 10 mg PO
Sig: Take 1 tablet once daily in the morning
Disp: 30 tablets
Refills: 3

Liraglutide 0.6 mg subcutaneous injection
Sig: Inject 0.6 mg once daily, titrate as directed
Disp: 2 pre-filled pens
Refills: 0

Atorvastatin 40 mg PO
Sig: Take 1 tablet once daily at bedtime
Disp: 30 tablets
Refills: 3

Lisinopril 10 mg PO
Sig: Take 1 tablet once daily
Disp: 30 tablets
Refills: 3

Aspirin 81 mg PO
Sig: Take 1 tablet once daily
Disp: 90 tablets
Refills: 3

Instructions:
- Empagliflozin reduces CV death (Class I recommendation)
- Liraglutide reduces CV events and death
- Statin for LDL-C reduction ≥50% (target <55 mg/dL if very high CV risk)
- ACEI/ARB for CV protection and renal protection
- Aspirin 75-160 mg daily for secondary prevention

Specific medication choices for CV benefit: 1

• SGLT-2i: Empagliflozin, canagliflozin, or dapagliflozin reduce CV events
• Empagliflozin specifically reduces risk of death
• GLP-1 RA: Liraglutide, semaglutide, or dulaglutide reduce CV events
• Liraglutide specifically reduces risk of death

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Hypertension Management in T2DM

Initiate antihypertensive treatment when office BP >140/90 mmHg; target SBP 130 mmHg (range 130-139 mmHg in patients >65 years), DBP <80 mmHg but not <70 mmHg. 1

Prescription Template - Hypertension in T2DM

Lisinopril 10 mg PO
Sig: Take 1 tablet once daily
Disp: 30 tablets
Refills: 3

Amlodipine 5 mg PO
Sig: Take 1 tablet once daily
Disp: 30 tablets
Refills: 3

Instructions:
- Start with RAAS blocker (ACEI or ARB) + calcium channel blocker or thiazide diuretic
- Particularly important if microalbuminuria, proteinuria, or LV hypertrophy present
- Titrate lisinopril to 20-40 mg daily as needed
- Titrate amlodipine to 10 mg daily as needed
- Lifestyle modifications: sodium restriction, weight loss, physical activity

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Lipid Management in T2DM

All adults 40-75 years with diabetes require moderate-intensity statin therapy regardless of 10-year ASCVD risk; high-intensity statin reasonable if multiple ASCVD risk factors present. 1

Prescription Template - Lipid Management (Moderate CV Risk)

Atorvastatin 20 mg PO
Sig: Take 1 tablet once daily at bedtime
Disp: 30 tablets
Refills: 3

Instructions:
- Target: LDL-C reduction ≥30%
- Check lipid panel in 4-6 weeks
- If LDL-C not at goal, increase to atorvastatin 40 mg daily

Prescription Template - Lipid Management (High/Very High CV Risk)

Atorvastatin 80 mg PO
Sig: Take 1 tablet once daily at bedtime
Disp: 30 tablets
Refills: 3

Instructions:
- Target: LDL-C reduction ≥50%
- Very high CV risk target: LDL-C <55 mg/dL (<1.4 mmol/L)
- High CV risk target: LDL-C <70 mg/dL (<1.8 mmol/L)
- Check lipid panel in 4-6 weeks

Prescription Template - Statin + Ezetimibe (if target not reached)

Atorvastatin 80 mg PO
Sig: Take 1 tablet once daily at bedtime
Disp: 30 tablets
Refills: 3

Ezetimibe 10 mg PO
Sig: Take 1 tablet once daily
Disp: 30 tablets
Refills: 3

Instructions:
- Add ezetimibe if LDL-C target not reached on maximal statin
- Recheck lipid panel in 4-6 weeks
- If still not at goal on maximal statin + ezetimibe, consider PCSK9 inhibitor

Contraindication: Statins not recommended in women of childbearing potential. 1

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Medications to AVOID

Do NOT add DPP-4 inhibitors to metformin—they do not reduce morbidity or mortality and are inferior to SGLT-2i and GLP-1 RA. 2, 3

Do NOT use: 1, 2, 5

• Thiazolidinediones in patients with heart failure
• Saxagliptin in patients with high risk of heart failure
• Sulfonylureas as preferred agents (higher mortality and side effects vs SGLT-2i/GLP-1 RA)

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Monitoring Schedule

HbA1c monitoring: 2, 3

• Check every 3 months until target reached
• Once stable at target, check every 6 months
• Deintensify therapy if HbA1c <6.5% to reduce hypoglycemia risk

Blood glucose monitoring required for: 2

• Patients on insulin therapy
• Medications with hypoglycemia risk (sulfonylureas, insulin)
• Treatment initiation or changes
• Not meeting glycemic goals
• Intercurrent illness

Blood glucose monitoring may be unnecessary for: 3

• Patients on metformin + SGLT-2i or GLP-1 RA alone (no hypoglycemia risk)