What are the treatment options for type 2 diabetes management, including medication prescriptions and lifestyle modifications?

Type 2 Diabetes Management: Prescription Templates for All Clinical Scenarios

Initial Assessment and First-Line Therapy

Start metformin 500 mg PO daily with dinner immediately at diagnosis alongside lifestyle modifications for all newly diagnosed patients without contraindications. 1, 2

Prescription Template 1: Metabolically Stable Patient (A1C <8.5%, asymptomatic)

Rx: Metformin 500 mg tablets

• Sig: Take 1 tablet PO daily with dinner
• Disp: 30 tablets
• Refills: 3
• Instructions: Increase by 500 mg every 1-2 weeks as tolerated. Target dose 2000 mg daily in divided doses (1000 mg twice daily with meals). 1, 2

Lifestyle Prescription:

• Physical activity: 30-60 minutes moderate-intensity aerobic activity (brisk walking) 5-7 days/week 3
• Resistance training: 2-3 days/week 3
• Nutrition: Plant-predominant diet emphasizing nutrient-dense foods, eliminate sugar-added beverages 3
• Weight loss target: 5-10% body weight reduction 3

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Scenario 2: Marked Hyperglycemia Without Ketoacidosis

For patients with blood glucose ≥250 mg/dL OR A1C ≥8.5% who are symptomatic (polyuria, polydipsia, nocturia, weight loss) but WITHOUT ketoacidosis, initiate dual therapy immediately. 3, 1

Prescription Template 2A: Insulin + Metformin

Rx: Insulin glargine 100 units/mL (10 mL vial or 3 mL pen)

• Sig: Inject 0.5 units/kg subcutaneously once daily at bedtime
• Disp: 1 vial or 5 pens
• Refills: 3
• Instructions: Starting dose based on body weight. For 70 kg patient = 35 units daily. 1, 4

Rx: Metformin 500 mg tablets

• Sig: Take 1 tablet PO daily with dinner, increase by 500 mg weekly to target 2000 mg daily in divided doses
• Disp: 30 tablets
• Refills: 3 1

Rx: Blood glucose test strips

• Sig: Check fasting and bedtime blood glucose daily
• Disp: 100 strips
• Refills: 6 3

Insulin Adjustment Protocol:

• Increase insulin by 2-4 units every 3 days if fasting glucose >130 mg/dL 4
• Once glucose targets met for 2-6 weeks, taper insulin by 10-30% every few days while continuing metformin 3

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Scenario 3: Diabetic Ketoacidosis or Marked Ketosis

For patients with ketosis/ketoacidosis, initiate IV insulin immediately per DKA protocol, then transition to subcutaneous insulin with metformin after acidosis resolves. 3, 1

Prescription Template 3A: Acute Phase (Hospital/ED)

Rx: Regular insulin IV infusion

• Sig: 0.1 units/kg/hour continuous IV infusion per DKA protocol
• Continue until anion gap closes and pH >7.3 3

Prescription Template 3B: Post-Resolution Phase

Rx: Insulin glargine 100 units/mL

• Sig: Inject 0.5 units/kg subcutaneously once daily at bedtime
• Disp: 1 vial or 5 pens
• Refills: 3 1, 4

Rx: Insulin aspart 100 units/mL (rapid-acting)

• Sig: Inject 4-6 units subcutaneously before each meal, adjust based on carbohydrate intake
• Disp: 1 vial or 5 pens
• Refills: 3 3

Rx: Metformin 500 mg tablets

• Sig: Start 500 mg PO daily with dinner AFTER ketosis resolves, titrate to 2000 mg daily
• Disp: 30 tablets
• Refills: 3 3, 1

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Scenario 4: Inadequate Control on Metformin Monotherapy

When A1C remains above target after 3 months on maximum tolerated metformin dose, add SGLT-2 inhibitor or GLP-1 receptor agonist based on comorbidities. 2, 5

Prescription Template 4A: Patient with Cardiovascular Disease or High CV Risk

Rx: Empagliflozin 10 mg tablets

• Sig: Take 1 tablet PO daily in morning
• Disp: 30 tablets
• Refills: 3
• Instructions: SGLT-2 inhibitor reduces CV death and heart failure hospitalization by 18-26%. Ensure adequate hydration. 1, 2, 5

OR

Rx: 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
• Instructions: GLP-1 RA reduces stroke risk and provides weight loss >5-10%. Titrate to 1.0 mg weekly if needed for glycemic control. 1, 2, 5

Continue metformin 2000 mg daily in divided doses 1, 2

Prescription Template 4B: Patient with Chronic Kidney Disease (eGFR 30-60 mL/min/1.73 m²)

Rx: Canagliflozin 100 mg tablets

• Sig: Take 1 tablet PO daily before first meal
• Disp: 30 tablets
• Refills: 3
• Instructions: SGLT-2 inhibitor reduces CKD progression by 24-39%. Monitor kidney function. 1, 2, 5

Rx: Metformin 1000 mg tablets (if eGFR >30)

• Sig: Take 1 tablet PO twice daily with meals
• Disp: 60 tablets
• Refills: 3
• Instructions: Continue if eGFR >30 mL/min/1.73 m². Discontinue if eGFR <30. 1

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Scenario 5: Inadequate Control Despite Dual Therapy

For patients on metformin + SGLT-2i or GLP-1 RA not meeting A1C targets, add basal insulin. 3, 2

Prescription Template 5: Triple Therapy

Rx: Insulin detemir 100 units/mL

• Sig: Inject 0.2 units/kg (or 10 units) subcutaneously once daily at bedtime
• Disp: 1 vial or 5 pens
• Refills: 3
• Instructions: Alternative to glargine. Adjust dose by 2-4 units every 3 days based on fasting glucose. 6

Continue existing metformin and SGLT-2i/GLP-1 RA 2

Rx: Blood glucose test strips

• Sig: Check fasting glucose daily and pre-meal glucose 3 times weekly
• Disp: 150 strips
• Refills: 6 3

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Scenario 6: Basal Insulin Failure (>1.5 units/kg/day without target achievement)

Transition to multiple daily injections with basal-bolus regimen. 3

Prescription Template 6: Intensive Insulin Therapy

Rx: Insulin glargine 100 units/mL

• Sig: Inject 50% of current total daily dose subcutaneously once daily at bedtime
• Disp: 2 vials or 10 pens
• Refills: 3 3, 4

Rx: Insulin lispro 100 units/mL (rapid-acting)

• Sig: Inject subcutaneously before each meal. Starting dose: divide remaining 50% of total daily dose into 3 pre-meal doses. Match to carbohydrate intake (1 unit per 10-15g carbs).
• Disp: 2 vials or 10 pens
• Refills: 3 3

Rx: Blood glucose test strips

• Sig: Check before each meal and at bedtime (4 times daily)
• Disp: 200 strips
• Refills: 6 3

Continue metformin 3, 2

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Scenario 7: Pediatric/Adolescent Type 2 Diabetes (Ages 10-18)

For youth with type 2 diabetes, treatment algorithms differ based on presentation severity. 3

Prescription Template 7A: Pediatric Patient - Metabolically Stable (A1C <8.5%)

Rx: Metformin 500 mg tablets

• Sig: Take 1 tablet PO daily with dinner
• Disp: 30 tablets
• Refills: 3
• Instructions: Increase by 500 mg every 1-2 weeks to maximum 2000 mg daily in divided doses. First-line therapy for youth. 3

Family-centered lifestyle prescription:

• Physical activity: 30-60 minutes moderate-to-vigorous activity 5 days/week PLUS strength training 3 days/week 3
• Eliminate sugar-added beverages completely 3
• Family-based nutrition counseling focusing on nutrient-dense foods 3
• Target: 7-10% decrease in excess weight 3

Prescription Template 7B: Pediatric Patient - Marked Hyperglycemia (Glucose ≥250 mg/dL OR A1C ≥8.5%)

Rx: Insulin glargine 100 units/mL

• Sig: Inject 0.5 units/kg subcutaneously once daily at bedtime
• Disp: 1 vial or 5 pens
• Refills: 3 3

Rx: Metformin 500 mg tablets

• Sig: Take 1 tablet PO daily with dinner, titrate to 2000 mg daily
• Disp: 30 tablets
• Refills: 3 3

Prescription Template 7C: Pediatric Patient - Ketosis/DKA

Initiate insulin therapy immediately (IV if DKA, subcutaneous if ketosis without acidosis). 3

After acidosis resolution:

Rx: Insulin glargine 100 units/mL

• Sig: Inject 0.5 units/kg subcutaneously once daily
• Disp: 1 vial or 5 pens
• Refills: 3 3

Rx: Metformin 500 mg tablets

• Sig: Start after ketosis resolves. Take 1 tablet PO daily, titrate to 2000 mg daily
• Disp: 30 tablets
• Refills: 3 3

Prescription Template 7D: Pediatric Patient - Metformin Failure (Age ≥10 years)

Rx: Liraglutide 0.6 mg/mL subcutaneous injection pen

• Sig: Inject 0.6 mg subcutaneously once daily for 1 week, then increase to 1.2 mg daily
• Disp: 2 pens
• Refills: 3
• Instructions: Only GLP-1 RA approved for youth ≥10 years. Contraindicated with personal/family history of medullary thyroid carcinoma or MEN type 2. 3

Continue metformin 2000 mg daily 3

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Monitoring Requirements for All Scenarios

A1C Monitoring:

• Check every 3 months until target achieved 3, 1, 2
• Once at target, check every 6 months 1

Blood Glucose Monitoring Frequency:

• Metformin alone: Periodic monitoring, individualized 3
• Basal insulin: Fasting glucose daily 3
• Multiple daily injections: Before each meal and bedtime (4 times daily) 3
• During insulin titration: Increase frequency 4

Glycemic Targets:

• Most adults: A1C <7% 1, 2
• Selected individuals (if achievable without hypoglycemia): A1C <6.5% 3, 1
• Pediatric patients on oral agents: A1C <7% 3
• Less stringent targets (7-8%): Patients with limited life expectancy, severe hypoglycemia history, advanced complications, extensive comorbidities 3, 2

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Critical Prescribing Considerations

Metformin Contraindications:

• eGFR <30 mL/min/1.73 m² (absolute) 1
• Active liver disease 2
• Severe heart failure 2

Insulin Dosing Adjustments:

• When switching from NPH twice daily to glargine once daily: Use 80% of total NPH dose 4
• When switching from NPH once daily to glargine: Use same dose 4
• Renal impairment: May require dose reduction 4, 6
• Hepatic impairment: May require dose reduction 6

SGLT-2 Inhibitor Precautions:

• Risk of genital mycotic infections 2
• Ensure adequate hydration to prevent volume depletion 2
• Monitor for diabetic ketoacidosis (rare but serious) 2

GLP-1 RA Contraindications:

• Personal or family history of medullary thyroid carcinoma 3
• Multiple endocrine neoplasia type 2 3

Avoid These Medications:

• DPP-4 inhibitors: Inferior outcomes compared to SGLT-2i/GLP-1 RA for mortality and morbidity 2
• Sulfonylureas: Higher mortality and side effects versus SGLT-2i/GLP-1 RA 2
• Thiazolidinediones: Increased fracture risk, fluid retention 3

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Deprescribing Protocol

When A1C <6.5% on current regimen, deintensify therapy to reduce hypoglycemia risk. 2

Insulin Tapering (when glucose targets met for 2-6 weeks):

• Decrease dose by 10-30% every few days 3
• Continue metformin throughout taper 3
• Monitor fasting glucose during taper 3

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Cardiovascular Risk Reduction (All Patients)

Rx: Atorvastatin 40 mg tablets (or equivalent high-intensity statin)

• Sig: Take 1 tablet PO daily at bedtime
• Disp: 30 tablets
• Refills: 11
• Instructions: All adults 40-75 years with diabetes require statin therapy. Target ≥50% LDL-C reduction. 3, 2

Rx: Aspirin 81 mg tablets

• Sig: Take 1 tablet PO daily
• Disp: 30 tablets
• Refills: 11
• Instructions: For secondary prevention in patients with established cardiovascular disease. 3

Blood Pressure Target: <140/90 mmHg (individualize based on comorbidities) 3