What are the prescription templates for type 2 diabetes management, including first-line and second-line treatments, and considerations for patients with Impaired renal function, cardiovascular risk factors, and hypoglycemia risk?

Medical Advisory BoardAll articles are reviewed for accuracy by our Medical Advisory Board
Educational purpose only • Exercise caution as content is pending human review
Article Review Status
Submitted
Under Review
Approved

Last updated: November 25, 2025 • View editorial policy

Personalize

Help us tailor your experience

Which best describes you? Your choice helps us use language that's most understandable for you.

Type 2 Diabetes Prescription Templates: Complete Clinical Scenarios

First-Line Treatment (All Patients Without Contraindications)

Start all patients with metformin 500-850 mg once or twice daily with meals, titrating up to 2000-2550 mg daily over 4-8 weeks as tolerated, combined with lifestyle modifications. 1, 2

Metformin Prescription Template:

Rx: Metformin 500 mg tablets
Sig: Take 1 tablet by mouth twice daily with meals
Disp: 60 tablets
Refills: 3
Instructions: Start with 500 mg once or twice daily, increase by 500 mg weekly as tolerated to target dose of 1000 mg twice daily. May cause GI upset initially.

Monitor vitamin B12 levels annually in all patients on long-term metformin, especially those with anemia or peripheral neuropathy. 1

Second-Line Treatment: Adding SGLT-2 Inhibitor or GLP-1 Agonist

Scenario 1: Patient with Heart Failure or Chronic Kidney Disease

Add an SGLT-2 inhibitor immediately to metformin—this is the mandatory choice for these patients. 1, 2

Empagliflozin Prescription Template (Preferred for CV Death Reduction):

Rx: Empagliflozin 10 mg tablets
Sig: Take 1 tablet by mouth once daily in the morning
Disp: 30 tablets
Refills: 3
Instructions: May increase to 25 mg daily after 4 weeks if additional glycemic control needed. Ensure adequate hydration. Monitor for genital mycotic infections.

Dapagliflozin Prescription Template:

Rx: Dapagliflozin 10 mg tablets
Sig: Take 1 tablet by mouth once daily in the morning
Disp: 30 tablets
Refills: 3
Instructions: Ensure adequate hydration. Monitor for genital mycotic infections and urinary tract infections.

SGLT-2 inhibitors can be initiated with eGFR ≥20 mL/min/1.73 m², though glycemic benefits diminish below eGFR <45 mL/min/1.73 m². 1

Scenario 2: Patient with High Stroke Risk or Weight Loss Goals

Add a GLP-1 receptor agonist to metformin—this is the mandatory choice for stroke prevention and weight management. 1, 2

Liraglutide Prescription Template (Preferred for Mortality Reduction):

Rx: Liraglutide 18 mg/3 mL pen (Victoza)
Sig: Inject 0.6 mg subcutaneously once daily for 1 week, then increase to 1.2 mg daily
Disp: 2 pens (6 mL total)
Refills: 3
Instructions: May increase to 1.8 mg daily after 1 week at 1.2 mg if tolerated. Inject in abdomen, thigh, or upper arm. Rotate injection sites. May cause nausea initially.

Semaglutide Prescription Template (Weekly Dosing):

Rx: Semaglutide 2 mg/1.5 mL pen (Ozempic)
Sig: Inject 0.25 mg subcutaneously once weekly for 4 weeks
Disp: 1 pen
Refills: 3
Instructions: After 4 weeks, increase to 0.5 mg weekly. May increase to 1 mg weekly after 4 weeks at 0.5 mg, then to 2 mg weekly if needed. Inject on same day each week.

Dulaglutide Prescription Template (Weekly Dosing):

Rx: Dulaglutide 0.75 mg/0.5 mL pen (Trulicity)
Sig: Inject 0.75 mg subcutaneously once weekly
Disp: 4 pens
Refills: 3
Instructions: May increase to 1.5 mg weekly after 4 weeks if additional glycemic control needed. Inject on same day each week.

Scenario 3: Patient with Established Atherosclerotic Cardiovascular Disease

Use either an SGLT-2 inhibitor OR a GLP-1 agonist—both classes reduce MACE and all-cause mortality. 1, 2

  • Choose SGLT-2 inhibitor if patient also has heart failure 1
  • Choose GLP-1 agonist if patient needs weight loss or has high stroke risk 1, 2

Scenario 4: Patient with Advanced CKD (eGFR <30 mL/min/1.73 m²)

Use a GLP-1 receptor agonist as the preferred add-on agent due to lower hypoglycemia risk and cardiovascular benefits. 1

Avoid SGLT-2 inhibitors for glycemic control at this stage, though they may still provide kidney and heart failure benefits. 1

Third-Line Treatment Options

Scenario 5: Patient Not at Goal on Metformin + SGLT-2i or GLP-1 RA

Add the complementary agent (if on SGLT-2i, add GLP-1 RA; if on GLP-1 RA, add SGLT-2i) before considering other options. 1, 2

Combination Template:

Continue: Metformin 1000 mg twice daily
Continue: Empagliflozin 25 mg once daily
Add: Liraglutide 1.8 mg subcutaneously once daily

When adequate glycemic control is achieved with this combination, reduce or discontinue any existing sulfonylureas or long-acting insulins to prevent severe hypoglycemia. 1, 2

Scenario 6: Patient Requiring Additional Glycemic Control (Cost-Constrained)

If SGLT-2 inhibitors and GLP-1 agonists are unaffordable, consider DPP-4 inhibitors, sulfonylureas, or thiazolidinediones, but understand these are inferior for mortality and morbidity outcomes. 1, 2

Sitagliptin Prescription Template (DPP-4 Inhibitor):

Rx: Sitagliptin 100 mg tablets
Sig: Take 1 tablet by mouth once daily
Disp: 30 tablets
Refills: 3
Instructions: Reduce dose to 50 mg daily if eGFR 30-45 mL/min/1.73 m²; reduce to 25 mg daily if eGFR <30 mL/min/1.73 m².

Note: The American College of Physicians strongly recommends AGAINST adding DPP-4 inhibitors to metformin for reducing morbidity and mortality. 1

Glipizide Prescription Template (Sulfonylurea - Use with Extreme Caution):

Rx: Glipizide 5 mg tablets
Sig: Take 1 tablet by mouth once daily with breakfast
Disp: 30 tablets
Refills: 3
Instructions: May increase by 2.5-5 mg every 1-2 weeks to maximum 20 mg daily. HIGH RISK OF HYPOGLYCEMIA. Counsel patient on hypoglycemia symptoms.

Sulfonylureas carry significant hypoglycemia risk and are inferior to SGLT-2 inhibitors and GLP-1 agonists for cardiovascular outcomes. 1, 2

Pioglitazone Prescription Template (Thiazolidinedione):

Rx: Pioglitazone 15 mg tablets
Sig: Take 1 tablet by mouth once daily
Disp: 30 tablets
Refills: 3
Instructions: May increase to 30 mg daily after 4-8 weeks if needed. Monitor for weight gain and edema. CONTRAINDICATED in heart failure.

Thiazolidinediones are absolutely contraindicated in patients with heart failure (NYHA Class III or IV). 1, 3

Insulin Therapy Scenarios

Scenario 7: Severe Hyperglycemia at Presentation

Initiate insulin immediately if HbA1c >10% (>86 mmol/mol), fasting glucose ≥300 mg/dL (≥16.7 mmol/L), or patient has symptoms of hyperglycemia or unintentional weight loss. 1

Basal Insulin Prescription Template:

Rx: Insulin glargine U-100 (Lantus) 10 mL vial
Sig: Inject 10 units subcutaneously once daily at bedtime
Disp: 1 vial
Refills: 3
Instructions: Check fasting blood glucose daily. Increase dose by 2 units every 3 days until fasting glucose 80-130 mg/dL. Target fasting glucose <130 mg/dL.
Continue metformin.

Scenario 8: Patient Not at Goal Despite Oral Agents

Prefer adding a GLP-1 receptor agonist (including dual GIP/GLP-1 RA) over insulin when possible for greater glycemic effectiveness, weight benefits, and lower hypoglycemia risk. 1, 4

If insulin is necessary, combine it with a GLP-1 receptor agonist for superior outcomes. 1

Insulin + GLP-1 RA Combination Template:

Continue: Metformin 1000 mg twice daily
Add: Insulin glargine 10 units subcutaneously at bedtime
Add: Liraglutide 1.2 mg subcutaneously once daily (titrate to 1.8 mg)
Instructions: The GLP-1 RA reduces insulin requirements and hypoglycemia risk while promoting weight loss.

Special Population Scenarios

Scenario 9: Patient with Impaired Renal Function (eGFR 30-60 mL/min/1.73 m²)

Continue metformin at reduced doses; add SGLT-2 inhibitor for kidney protection and cardiovascular benefits. 1

Rx: Metformin 500 mg tablets
Sig: Take 1 tablet by mouth twice daily with meals (maximum 1000 mg daily)
Disp: 60 tablets
Refills: 3

Rx: Empagliflozin 10 mg tablets
Sig: Take 1 tablet by mouth once daily
Disp: 30 tablets
Refills: 3
Instructions: Monitor kidney function every 3-6 months. Empagliflozin reduces CKD progression by 24-39%.

Scenario 10: Patient with eGFR 20-30 mL/min/1.73 m²

Continue metformin at lowest effective dose (500 mg daily); SGLT-2 inhibitor can still be used for kidney and heart failure benefits, though glycemic effect is minimal. 1

Rx: Metformin 500 mg tablets
Sig: Take 1 tablet by mouth once daily with dinner
Disp: 30 tablets
Refills: 3

Rx: Dapagliflozin 10 mg tablets
Sig: Take 1 tablet by mouth once daily
Disp: 30 tablets
Refills: 3
Instructions: Primary benefit is kidney protection, not glucose lowering at this eGFR.

Scenario 11: Patient with eGFR <20 mL/min/1.73 m² or on Dialysis

Discontinue metformin; use GLP-1 receptor agonist as preferred glucose-lowering agent. 1

DISCONTINUE: Metformin (contraindicated)

Rx: Liraglutide 18 mg/3 mL pen
Sig: Inject 0.6 mg subcutaneously once daily, titrate to 1.8 mg
Disp: 2 pens
Refills: 3
Instructions: Preferred agent at this kidney function level. Low hypoglycemia risk.

Scenario 12: Patient with High Hypoglycemia Risk (Elderly, Living Alone, History of Severe Hypoglycemia)

Use metformin + SGLT-2 inhibitor or GLP-1 agonist exclusively; avoid sulfonylureas and insulin if possible. 1, 2

Target HbA1c 7.5-8.5% in this population to minimize hypoglycemia risk. 1

Rx: Metformin 1000 mg tablets
Sig: Take 1 tablet by mouth twice daily with meals
Disp: 60 tablets
Refills: 3

Rx: Empagliflozin 10 mg tablets
Sig: Take 1 tablet by mouth once daily
Disp: 30 tablets
Refills: 3
Instructions: These medications do NOT cause hypoglycemia when used together. No need for frequent glucose monitoring.

Monitoring and Follow-Up Protocols

Initial 3-Month Follow-Up Template:

  • Check HbA1c at 3 months after any medication change 1, 2
  • If HbA1c not at goal (7-8%), intensify therapy immediately—do not delay 1, 4
  • Check basic metabolic panel for kidney function 1
  • Assess for medication side effects and adherence 2

Ongoing Monitoring Template:

  • HbA1c every 3-6 months once stable 1
  • Annual comprehensive metabolic panel 1
  • Annual vitamin B12 level if on metformin 1
  • Kidney function (eGFR and urine albumin-to-creatinine ratio) at least annually, more frequently if eGFR <60 mL/min/1.73 m² 1

Critical Safety Protocols

When to Reduce or Stop Medications:

Deintensify treatment when HbA1c <6.5% to prevent hypoglycemia and overtreatment. 1, 2

When adding SGLT-2 inhibitor or GLP-1 agonist achieves adequate control, immediately reduce or discontinue sulfonylureas or long-acting insulins. 1, 2

Hypoglycemia Risk Reduction Template:

Current regimen: Metformin 1000 mg twice daily + Glipizide 10 mg twice daily
New HbA1c: 6.8% (previously 8.5%)
Patient started empagliflozin 10 mg daily 3 months ago

ACTION REQUIRED:
REDUCE: Glipizide to 5 mg once daily immediately
CONTINUE: Metformin 1000 mg twice daily
CONTINUE: Empagliflozin 10 mg daily
RECHECK: HbA1c in 3 months
GOAL: Eliminate glipizide entirely if HbA1c remains <7%

Cardiovascular Risk Management (Mandatory Concurrent Prescriptions)

All Patients with Type 2 Diabetes and Cardiovascular Disease:

Prescribe ACE inhibitor or ARB regardless of blood pressure for cardiovascular event reduction. 1

Rx: Lisinopril 10 mg tablets
Sig: Take 1 tablet by mouth once daily
Disp: 30 tablets
Refills: 3
Instructions: Titrate to 20-40 mg daily as tolerated. Monitor potassium and creatinine.

Prescribe high-intensity statin for LDL-C target <55 mg/dL (<1.4 mmol/L) with ≥50% reduction from baseline. 1

Rx: Atorvastatin 40 mg tablets
Sig: Take 1 tablet by mouth once daily at bedtime
Disp: 30 tablets
Refills: 3
Instructions: Target LDL-C <55 mg/dL. Check lipid panel in 6 weeks.

Prescribe aspirin 75-160 mg daily for secondary prevention. 1

Rx: Aspirin 81 mg tablets
Sig: Take 1 tablet by mouth once daily
Disp: 90 tablets
Refills: 3
Instructions: Take with food to reduce GI upset.

Lifestyle Modification Prescription Template

Write formal lifestyle prescriptions with specific, measurable targets: 2, 5

LIFESTYLE PRESCRIPTION:

1. Physical Activity:
   - 150 minutes moderate-intensity aerobic activity per week (30 minutes, 5 days/week)
   - Examples: Brisk walking, cycling, swimming
   - Start with 10-minute sessions if needed, gradually increase

2. Dietary Modifications:
   - Calorie restriction: 1500 kcal/day
   - Fat intake: <30-35% of total calories
   - Increase: 2-3 servings fruits daily, 2-3 servings vegetables daily
   - Low-fat dairy products
   - Sodium restriction: <2 g sodium/day (<5 g salt/day)

3. Weight Loss Goal:
   - Target: 5-10% body weight reduction over 6 months
   - Current weight: ___ kg
   - Target weight: ___ kg

4. Alcohol Restriction:
   - Limit to ≤1 drink/day for women, ≤2 drinks/day for men

5. Follow-up:
   - Dietitian referral: Yes
   - Diabetes educator referral: Yes
   - Return visit: 4 weeks

Cost-Conscious Prescribing Strategies

When SGLT-2 inhibitors and GLP-1 agonists are unaffordable, discuss this limitation explicitly with patients and document the conversation. 1, 2

Always prescribe generic formulations when available. 1, 2

Cost-Constrained Alternative Template:

Discussed with patient: SGLT-2 inhibitors and GLP-1 agonists are superior for reducing death and cardiovascular events but are expensive with no generic options currently available.

Patient preference: Cannot afford brand-name medications

Alternative regimen:
Rx: Metformin 1000 mg tablets (GENERIC)
Sig: Take 1 tablet by mouth twice daily with meals
Disp: 60 tablets
Refills: 3

Rx: Glipizide XL 5 mg tablets (GENERIC)
Sig: Take 1 tablet by mouth once daily with breakfast
Disp: 30 tablets
Refills: 3
Instructions: CAUTION - Risk of hypoglycemia. Counsel on symptoms. Carry glucose tablets.

Plan: Reassess financial situation at each visit. Switch to SGLT-2i or GLP-1 RA when feasible.

What NOT to Do (Critical Pitfalls)

NEVER add a DPP-4 inhibitor to metformin as second-line therapy—this is a strong recommendation against based on high-certainty evidence showing no mortality or morbidity benefit. 1

NEVER prescribe thiazolidinediones (pioglitazone) to patients with any degree of heart failure. 1, 3

NEVER use saxagliptin in patients with high heart failure risk. 1

NEVER delay treatment intensification when HbA1c is not at goal—intensify immediately. 1, 4

NEVER continue sulfonylureas or long-acting insulin at full doses after adding SGLT-2 inhibitors or GLP-1 agonists—reduce or discontinue them to prevent severe hypoglycemia. 1, 2

NEVER target HbA1c <6.5% in most patients—this causes overtreatment and hypoglycemia risk. 1, 2

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

2
Guideline

Treatment Guidelines for Type 2 Diabetes

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

4
Guideline

Pharmacological Treatments for Type 2 Diabetes

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

5
Research

Lifestyle intervention: nutrition therapy and physical activity.

The Medical clinics of North America, 2015

Related Questions

What is the initial treatment plan for a diabetic patient?
What is the initial management approach for patients with diabetes type 2 (DM2)?
What is the initial treatment plan for type 2 diabetes?
What is not a recognized mechanism of pancreatic cell destruction in type 2 Diabetes Mellitus (DM) among lipotoxicity, genetic factors, insulin toxicity, insulin resistance, and environmental factors?
What is the most appropriate initial test to confirm the cause of neurologic deficits in an 80-year-old man with progressive gait disturbance, forgetfulness, and frequent falls, who has type 2 diabetes (T2D), reduced deep tendon reflexes, and loss of proprioception?
What multivitamin is recommended for a 2-year-old?
What medications are used to treat Acute Kidney Injury (AKI)?
What is the recommended timeframe for retesting after initiating testosterone replacement therapy in a patient with hypogonadism?
What medication combines diclofenac and B vitamins?
What is the appropriate treatment for a patient with a urinary tract infection showing many bacteria and no white blood cells (WBCs) on urinalysis?
What is the recommended follow-up interval for MRI in an elderly male with a small 1 cm left adrenal adenoma?

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

Have a follow-up question?

Our Medical A.I. is used by practicing medical doctors at top research institutions around the world. Ask any follow up question and get world-class guideline-backed answers instantly.

Ask Question