Type 2 Diabetes Mellitus Prescription Templates
Template 1: Newly Diagnosed, Metabolically Stable (A1C <8.5%, No Ketosis)
Start metformin 500 mg PO daily with dinner immediately at diagnosis alongside lifestyle modifications. 1, 2
Prescription:
- Metformin 500 mg tablets
- Sig: Take 1 tablet by mouth daily with dinner
- Disp: 30 tablets
- Refills: 3
- Titration: Increase by 500 mg every 1-2 weeks as tolerated to target dose of 2000 mg daily in divided doses (1000 mg twice daily with meals) 2
Lifestyle prescription:
- 60 minutes moderate-to-vigorous physical activity daily (for youth) 1 or 150 minutes/week spread over at least 3 days (for adults) 1
- Limit screen time to <2 hours daily 1
- Restrict calorie intake to 1500 kcal/day, with fat <30-35% of total energy 1
- Eliminate sugar-sweetened beverages 1
Monitoring: A1C every 3 months until target <7% achieved, then every 6 months 1, 2
Template 2: Newly Diagnosed with Severe Hyperglycemia (A1C ≥8.5% or Random Glucose ≥250 mg/dL, No Ketoacidosis)
Initiate insulin therapy immediately along with metformin for patients presenting with marked hyperglycemia. 1, 2
Prescription Set:
Insulin Glargine:
- Insulin glargine 100 units/mL vial or pen
- Sig: Inject 0.5 units/kg subcutaneously once daily at bedtime
- Disp: 1 vial (10 mL) or 5 pens
- Refills: 3
Metformin:
- Metformin 500 mg tablets
- Sig: Take 1 tablet by mouth daily with dinner
- Disp: 30 tablets
- Refills: 3
- Titrate to 2000 mg daily as tolerated 1, 2
Supplies:
- Blood glucose meter with test strips (100 count)
- Lancets (100 count)
- Insulin syringes or pen needles
- Sharps container
Monitoring: Finger-stick blood glucose before meals and at bedtime initially; A1C every 3 months 1
Template 3: Diabetic Ketoacidosis or Marked Ketosis
Admit for intravenous insulin infusion per DKA protocol until acidosis resolves, then transition to subcutaneous insulin. 1
Hospital Protocol:
- IV insulin infusion 0.1 units/kg/hour until acidosis resolves 1
- Transition to subcutaneous basal-bolus regimen
Discharge Prescription Set:
Long-acting Insulin:
- Insulin glargine 100 units/mL
- Sig: Inject 0.5 units/kg subcutaneously once daily at bedtime
- Disp: 2 vials or 5 pens
- Refills: 3
Rapid-acting Insulin:
- Insulin lispro or aspart 100 units/mL
- Sig: Inject before meals based on carbohydrate counting (starting 1 unit per 15g carbohydrate)
- Disp: 2 vials or 5 pens
- Refills: 3
Metformin (after ketosis resolution):
- Metformin 500 mg tablets
- Sig: Take 1 tablet by mouth daily with dinner, increase as tolerated
- Disp: 30 tablets
- Refills: 3
Template 4: Patient with Established Cardiovascular Disease or Heart Failure
Add cardioprotective agents (SGLT2 inhibitor or GLP-1 receptor agonist) to metformin for patients with cardiovascular disease. 2, 3
Prescription Set:
Metformin:
- Metformin 500 mg tablets
- Sig: Take 1 tablet by mouth twice daily with meals
- Disp: 60 tablets
- Refills: 3
Empagliflozin (SGLT2 inhibitor):
- Empagliflozin 10 mg tablets
- Sig: Take 1 tablet by mouth once daily in the morning
- Disp: 30 tablets
- Refills: 3
- May increase to 25 mg daily if needed 4
Alternative: Semaglutide (GLP-1 RA):
- Semaglutide 0.25 mg/0.5 mL subcutaneous injection pen
- Sig: Inject 0.25 mg subcutaneously once weekly for 4 weeks, then increase to 0.5 mg weekly
- Disp: 4 pens (0.25 mg) initially, then 4 pens (0.5 mg)
- Refills: 3
- May titrate to 1.0 mg weekly if needed 2
Rationale: SGLT2 inhibitors reduce cardiovascular events by 12-26% and heart failure by 18-25% over 2-5 years 3
Template 5: Patient with Chronic Kidney Disease (eGFR 30-60 mL/min/1.73 m²)
Use metformin if eGFR >30 mL/min/1.73 m² and add SGLT2 inhibitor for renal protection. 2, 3
Prescription Set:
Metformin (if eGFR >30):
- Metformin 500 mg tablets
- Sig: Take 1 tablet by mouth twice daily with meals
- Disp: 60 tablets
- Refills: 3
- Monitor renal function every 3-6 months 4
Empagliflozin:
- Empagliflozin 10 mg tablets
- Sig: Take 1 tablet by mouth once daily
- Disp: 30 tablets
- Refills: 3
Alternative: Canagliflozin:
- Canagliflozin 100 mg tablets
- Sig: Take 1 tablet by mouth once daily before first meal
- Disp: 30 tablets
- Refills: 3
Rationale: SGLT2 inhibitors reduce kidney disease progression by 24-39% 3
Template 6: Pediatric/Adolescent Patient (Age 10-18 years)
Initiate metformin with intensive family-centered lifestyle intervention for youth with type 2 diabetes. 1, 2
Prescription:
Metformin:
- Metformin 500 mg tablets
- Sig: Take 1 tablet by mouth once daily with dinner
- Disp: 30 tablets
- Refills: 3
- Titrate by 500 mg weekly to maximum 2000 mg daily in divided doses 1
If A1C ≥8.5% or ketosis present, add insulin:
- Insulin glargine 100 units/mL
- Sig: Inject 0.5 units/kg subcutaneously once daily at bedtime
- Disp: 1 vial or 5 pens
- Refills: 3
Lifestyle requirements:
- 60 minutes moderate-to-vigorous physical activity daily 1
- Muscle/bone strengthening 3 days/week 1
- Screen time <2 hours daily 1
- Family-based nutrition counseling 1
Target A1C: <7% (may aim for <6.5% if achievable without hypoglycemia) 1
Template 7: Inadequate Control on Metformin Monotherapy (A1C >7% after 3-6 months)
Add a second agent when metformin monotherapy fails to achieve glycemic targets. 1, 2
Option A: Add SGLT2 Inhibitor
Existing Metformin:
- Continue metformin 1000 mg twice daily
Add Empagliflozin:
- Empagliflozin 10 mg tablets
- Sig: Take 1 tablet by mouth once daily
- Disp: 30 tablets
- Refills: 3
- May increase to 25 mg if needed 4
Option B: Add GLP-1 Receptor Agonist
Existing Metformin:
- Continue metformin 1000 mg twice daily
Add Semaglutide:
- Semaglutide 0.25 mg subcutaneous injection pen
- Sig: Inject 0.25 mg subcutaneously once weekly for 4 weeks, then 0.5 mg weekly
- Disp: 4 pens (0.25 mg dose)
- Refills: 3
Option C: Add Basal Insulin
Existing Metformin:
- Continue metformin 1000 mg twice daily
Add Insulin Glargine:
- Insulin glargine 100 units/mL
- Sig: Inject 10 units (or 0.1-0.2 units/kg) subcutaneously once daily at bedtime
- Disp: 1 vial or 5 pens
- Refills: 3
- Titrate by 2 units every 3 days to achieve fasting glucose 80-130 mg/dL 4
Template 8: Triple Combination Therapy (Inadequate Control on Dual Therapy)
Combine metformin, SGLT2 inhibitor, and GLP-1 receptor agonist for optimal cardio-renal protection when dual therapy is insufficient. 5
Prescription Set:
Metformin:
- Metformin 1000 mg tablets
- Sig: Take 1 tablet by mouth twice daily with meals
- Disp: 60 tablets
- Refills: 3
Empagliflozin:
- Empagliflozin 25 mg tablets
- Sig: Take 1 tablet by mouth once daily
- Disp: 30 tablets
- Refills: 3
Semaglutide:
- Semaglutide 1.0 mg subcutaneous injection pen
- Sig: Inject 1.0 mg subcutaneously once weekly
- Disp: 4 pens
- Refills: 3
Rationale: Triple combination reduces 3-point MACE, total mortality, and heart failure better than other combinations 5
Template 9: Patient Requiring Insulin with Oral Agents (Basal-Plus Regimen)
Add basal insulin to existing oral agents when triple oral therapy is insufficient. 1, 4
Prescription Set:
Continue Existing Oral Agents:
- Metformin 1000 mg twice daily
- Empagliflozin 25 mg once daily
Add Insulin Glargine:
- Insulin glargine 100 units/mL (U-100)
- Sig: Inject 10 units subcutaneously once daily at bedtime (or 0.1-0.2 units/kg)
- Disp: 2 vials or 5 pens
- Refills: 3
- Titrate by 2 units every 3 days based on fasting glucose 4
Monitoring supplies:
- Blood glucose meter with strips
- Test fasting glucose daily initially
- A1C every 3 months 1
Template 10: Patient on Basal Insulin with Inadequate Control (Add Prandial Insulin)
Transition to basal-bolus regimen when basal insulin alone is insufficient. 4
Prescription Set:
Basal Insulin:
- Insulin glargine 100 units/mL
- Sig: Inject current dose subcutaneously once daily at bedtime
- Disp: 2 vials or 5 pens
- Refills: 3
Prandial Insulin:
- Insulin lispro 100 units/mL
- Sig: Inject 4 units (or 10% of basal dose) subcutaneously before each meal
- Disp: 2 vials or 5 pens
- Refills: 3
- Adjust based on pre-meal and 2-hour post-meal glucose 4
Continue Metformin:
- Metformin 1000 mg twice daily
Alternative: Premixed Insulin 70/30
- Insulin 70/30 (70% NPH, 30% regular)
- Sig: Inject 10-20 units subcutaneously twice daily (before breakfast and dinner)
- Disp: 2 vials or 5 pens
- Refills: 3
- Effective in obese patients 6
Template 11: Patient with Obesity (BMI >30 kg/m²) Requiring Weight Loss
Prioritize GLP-1 receptor agonist or dual GIP/GLP-1 receptor agonist for significant weight reduction. 3
Prescription Set:
Metformin:
- Metformin 1000 mg tablets
- Sig: Take 1 tablet by mouth twice daily with meals
- Disp: 60 tablets
- Refills: 3
Semaglutide (high-potency GLP-1 RA):
- Semaglutide 0.25 mg subcutaneous injection pen
- Sig: Inject 0.25 mg subcutaneously once weekly for 4 weeks, then 0.5 mg weekly for 4 weeks, then 1.0 mg weekly
- Disp: 4 pens (titration pack)
- Refills: 3
- Expected weight loss >5% in most patients, may exceed 10% 3
Lifestyle prescription:
- Target 7-10% decrease in excess weight 1
- 1500 kcal/day diet 1
- 150 minutes/week moderate-intensity exercise 1
Template 12: Patient on Sulfonylurea (Transition to Modern Therapy)
Discontinue sulfonylurea and transition to SGLT2 inhibitor or GLP-1 receptor agonist due to lower mortality and fewer side effects. 5
Discontinue:
- Stop current sulfonylurea (e.g., glipizide, glyburide)
New Prescription Set:
Continue Metformin:
- Metformin 1000 mg twice daily
Add Empagliflozin:
- Empagliflozin 10 mg tablets
- Sig: Take 1 tablet by mouth once daily
- Disp: 30 tablets
- Refills: 3
Rationale: Sulfonylureas associated with higher mortality and hypoglycemia risk compared to SGLT2 inhibitors and GLP-1 receptor agonists 5
Monitor: Check glucose more frequently during transition; expect slight increase initially but better long-term outcomes 5
Template 13: Patient with Insulin Resistance and Obesity (Add Pioglitazone)
Consider thiazolidinedione for patients with marked insulin resistance when other agents are insufficient or contraindicated. 4, 3
Prescription Set:
Metformin:
- Metformin 1000 mg twice daily
Pioglitazone:
- Pioglitazone 30 mg tablets
- Sig: Take 1 tablet by mouth once daily
- Disp: 30 tablets
- Refills: 3
- May increase to 45 mg if needed 4
Empagliflozin (if adding to pioglitazone):
- Empagliflozin 10 mg tablets
- Sig: Take 1 tablet by mouth once daily
- Disp: 30 tablets
- Refills: 3
Monitoring: Weight, edema, bone density (fracture risk in women), bladder symptoms 4
Expected A1C reduction: 1.0-1.5% 1, 4
Template 14: Elderly Patient or Limited Life Expectancy (Less Stringent Goals)
Target A1C <8% for patients with limited life expectancy, advanced complications, or high hypoglycemia risk. 1
Prescription:
Metformin (if tolerated):
- Metformin 500 mg tablets
- Sig: Take 1 tablet by mouth twice daily with meals
- Disp: 60 tablets
- Refills: 3
- Lower doses acceptable 1
DPP-4 Inhibitor (low hypoglycemia risk):
- Sitagliptin 100 mg tablets (or 50 mg if eGFR 30-50)
- Sig: Take 1 tablet by mouth once daily
- Disp: 30 tablets
- Refills: 3
Avoid: Sulfonylureas (high hypoglycemia risk) 5
Target: A1C <8%, avoid hypoglycemia 1
Common Pitfalls and Caveats
Metformin contraindications: 4
- eGFR <30 mL/min/1.73 m²
- Acute kidney injury risk
- Severe liver disease
- Alcohol abuse
SGLT2 inhibitor precautions: 4
- Monitor for genital mycotic infections (4% incidence)
- Urinary tract infections (increased in females)
- Volume depletion in elderly
- Acute kidney injury during illness
- Diabetic ketoacidosis (rare but serious)
- Discontinue during acute illness
Insulin titration errors: 4
- Titrate basal insulin by 2 units every 3 days, not weekly
- Target fasting glucose 80-130 mg/dL
- If hypoglycemia occurs, reduce dose by 10-20%
GLP-1 RA side effects: 3
- Nausea common initially (improves with slow titration)
- Contraindicated in personal/family history of medullary thyroid cancer
- Pancreatitis risk (rare)
Pediatric considerations: 1
- Always involve family in treatment plan
- Screen for MODY if atypical presentation
- More aggressive initial treatment if A1C ≥8.5%
- Refer to pediatric endocrinology if insulin required or goals not met