From the Guidelines

Management of new onset diabetes should begin with lifestyle modifications and metformin therapy, as evidenced by the most recent guidelines 1.

Lifestyle modifications including a balanced diet, regular physical activity, and weight management are essential for all patients with new onset diabetes.
For type 2 diabetes, metformin is typically the first-line medication, starting at 500 mg once or twice daily with meals, gradually increasing to 1000 mg twice daily as tolerated to minimize gastrointestinal side effects.
If metformin alone is insufficient to achieve target blood glucose levels (typically HbA1c <7%), additional medications may be added based on patient characteristics, such as sulfonylureas, DPP-4 inhibitors, SGLT-2 inhibitors, or GLP-1 receptor agonists.
For type 1 diabetes, insulin therapy is essential from diagnosis, typically using a basal-bolus regimen with long-acting insulin and rapid-acting insulin.
Regular blood glucose monitoring is crucial, with targets generally 80-130 mg/dL before meals and <180 mg/dL after meals.
Patient education about hypoglycemia recognition and management is essential, as is regular screening for complications.

Metformin: starting at 500 mg once or twice daily with meals, gradually increasing to 1000 mg twice daily as tolerated.
Sulfonylureas: such as glipizide 5-10 mg daily.
DPP-4 inhibitors: such as sitagliptin 100 mg daily.
SGLT-2 inhibitors: such as empagliflozin 10-25 mg daily.
GLP-1 receptor agonists: such as semaglutide, weekly injection.

Basal-bolus regimen with long-acting insulin (like glargine 0.2-0.4 units/kg/day) and rapid-acting insulin (like lispro 0.05-0.1 units/kg per meal).
Regular blood glucose monitoring is crucial to adjust insulin doses.

From the Research

The management of new onset diabetes typically involves lifestyle modification and metformin as the first-line pharmacotherapy 2.
If metformin is not effective, sulfonylureas are often added as a second-line treatment, but their use is being reevaluated due to the availability of newer glucose-lowering drugs with potentially fewer side effects 2.
Sulfonylureas are potent glucose-lowering drugs, but they can increase the risk of hypoglycemia, and their use as a first-line treatment has been associated with increased risks of ischemic stroke, cardiovascular death, and all-cause mortality compared to metformin 3.

For patients with contraindications or intolerance to metformin, alternative initial monotherapy options include sulfonylureas, thiazolidinediones, glinides, α-glucosidase inhibitors, dipeptidyl peptidase-4 inhibitors, sodium-glucose cotransporter-2 inhibitors, insulins, and glucagon-like peptide-1 receptor agonists 4.
Glucagon-like peptide-1 receptor agonists have been shown to have a favorable efficacy and safety profile, with benefits including reduced HbA1c, body mass index, and blood pressure, as well as increased high-density lipoprotein cholesterol 4.
The choice of glucose-lowering drug as initial monotherapy should be based on individual patient characteristics, including comorbidities, medication tolerance, and lifestyle factors 5, 6.

Combination therapy with oral diabetes medications is often necessary to achieve and maintain glycemic control in patients with type 2 diabetes 5.
The use of combination therapy can help to target different pathogenic mechanisms and manage both fasting and postprandial blood glucose levels 5.
Newer agents and insulins have become available, enhancing the armamentarium of therapeutics for the treatment of diabetes 5.