Type 2 Diabetes Management: Inpatient and Outpatient Clinical Practice Guideline

Initial Assessment & Diagnosis

Screen all adults ≥45 years with FPG, 2-hour OGTT, or HbA1c; if normal, repeat every 3 years. 1

Perform HbA1c quarterly when therapy changes or goals unmet; twice yearly when stable and meeting targets 1
Use point-of-care HbA1c testing for immediate treatment decisions 1

Glycemic Targets (Individualized)

Target HbA1c <7% for most nonpregnant adults to reduce microvascular complications and long-term macrovascular disease. 1

More Stringent Targets (HbA1c <6.5%)

Short diabetes duration 1
Long life expectancy 1
No significant cardiovascular disease 1
Achievable without significant hypoglycemia 1

Less Stringent Targets (HbA1c <8%)

History of severe hypoglycemia 1
Limited life expectancy 1
Advanced micro/macrovascular complications 1
Extensive comorbidities 1
Longstanding diabetes difficult to control despite maximal therapy 1

Foundation: Lifestyle Interventions (Start Immediately)

Medical Nutrition Therapy

All patients should receive individualized MNT from a registered dietitian at diagnosis and ongoing. 1

Weight loss recommended for all overweight/obese patients 1
Low-carbohydrate, low-fat calorie-restricted, or Mediterranean diets effective for ≤2 years 1
Monitor lipids, renal function, and protein intake on low-carb diets (especially with nephropathy) 1

Physical Activity

Prescribe ≥150 min/week moderate-intensity aerobic activity (50-70% max HR), spread over ≥3 days with no more than 2 consecutive days without exercise. 1

Add resistance training ≥2×/week 1

Diabetes Self-Management Education (DSME)

Provide DSME at diagnosis and as needed thereafter, addressing psychosocial issues. 1

Effective self-management and quality of life are key outcomes 1

Pharmacologic Management Algorithm

STEP 1: First-Line Therapy (At Diagnosis)

Initiate metformin PLUS lifestyle interventions immediately at diagnosis unless contraindicated. 1, 2

Start metformin 500-850 mg once or twice daily with meals; titrate to 1000 mg twice daily (2000 mg/day total) over 1-2 weeks 2
Maximum effective dose: 2000-2550 mg/day 2
Continue metformin throughout treatment intensification unless contraindicated 1, 2

Exception—Immediate Insulin: If markedly symptomatic and/or HbA1c ≥10% or glucose ≥300-350 mg/dL, start basal-bolus insulin immediately (with or without metformin). 1, 2

STEP 2: Second-Line Agent Selection (If HbA1c >7% After 3 Months)

Select second agent based on comorbidities (cardiorenal protection priority), NOT solely on HbA1c. 1, 2

If Established ASCVD, Heart Failure, or High CV Risk:

Add SGLT2 inhibitor (preferred) or GLP-1 receptor agonist. 2

SGLT2i reduces HF hospitalizations 18-25% and CV events 2
GLP-1 RA reduces stroke risk 12-26%, promotes >5% weight loss 2

If Chronic Kidney Disease (eGFR 30-60 mL/min/1.73m²):

Add SGLT2 inhibitor (first choice) to minimize CKD progression (24-39% risk reduction). 2

For advanced CKD (eGFR <30), prefer GLP-1 RA due to lower hypoglycemia risk 2

If No ASCVD/HF/CKD but Weight Loss Goal:

Add GLP-1 receptor agonist for superior weight reduction (>5% in most patients). 2

If Cost/Access Barriers:

Sulfonylurea (low cost, but hypoglycemia risk; discontinue when advancing to insulin) 1, 2
DPP-4 inhibitor (weight-neutral, low hypoglycemia risk, modest HbA1c reduction 0.5-0.8%) 2

STEP 3: Triple Therapy or Insulin Initiation (If HbA1c >7% After 3-6 Months)

Consider early combination therapy (metformin + SGLT2i/GLP-1 RA) at diagnosis if HbA1c >8.5% or in younger patients to shorten time to goal. 1, 2

Option A: Add Third Oral/Injectable Agent

Add complementary mechanism (e.g., metformin + SGLT2i + GLP-1 RA) 1
Consider fixed-dose combinations to reduce pill burden 1

Option B: Initiate Basal Insulin

Start basal insulin (glargine, detemir, or degludec) 10 units once daily OR 0.1-0.2 units/kg/day at bedtime. 1, 2, 3

Continue metformin (reduces insulin requirements 20-30%) 2, 3
Discontinue sulfonylureas when starting insulin 1, 2
Titrate basal insulin:
- Increase by 2 units every 3 days if fasting glucose 140-179 mg/dL 2, 3
- Increase by 4 units every 3 days if fasting glucose ≥180 mg/dL 2, 3
- Target fasting glucose: 80-130 mg/dL 2, 3

Critical Threshold: When basal insulin reaches 0.5 units/kg/day without achieving HbA1c goal, STOP escalating basal insulin and add prandial insulin or GLP-1 RA. 1, 2, 3

STEP 4: Intensify Insulin Regimen (If Basal Insulin Alone Insufficient)

Prefer GLP-1 RA over prandial insulin when both viable (superior weight/hypoglycemia profile). 1, 2

If GLP-1 RA Added to Basal Insulin:

Provides greater glycemic effectiveness, beneficial weight effects, reduced hypoglycemia vs. insulin alone 1, 2

If Prandial Insulin Required:

Add rapid-acting insulin (lispro, aspart, glulisine) 4 units before largest meal OR 10% of basal dose. 2, 3

Administer 0-15 minutes before meals 2, 3
Titrate by 1-2 units every 3 days based on 2-hour post-meal glucose 2, 3
Target post-meal glucose: <180 mg/dL 2, 3

Medication Adjustment & De-Intensification

Reassess therapy every 3-6 months; adjust based on HbA1c, weight, side effects, and organ protection. 1, 2

When to De-Intensify:

HbA1c <6.5% or substantially below individualized target 1
Increased hypoglycemia risk 1
Frail older adults 1

Reduce or stop hypoglycemia-causing medications (sulfonylureas, insulin) when adding SGLT2i/GLP-1 RA. 1, 2

Hypoglycemia Management

Treat glucose <70 mg/dL with 15-20 g glucose (preferred) or any carbohydrate containing glucose; recheck in 15 minutes and repeat if needed. 1

Once normal, consume meal/snack to prevent recurrence 1
Prescribe glucagon for all at significant risk of severe hypoglycemia; train caregivers in administration 1
If hypoglycemia unawareness or ≥1 severe episode, raise glycemic targets for several weeks to reverse unawareness 1

Special Populations & Situations

Bariatric Surgery

Consider for adults with BMI >35 kg/m² and T2DM, especially if diabetes/comorbidities difficult to control. 1

Hospitalized Patients (Non-Critical)

Target glucose: 140-180 mg/dL 1
Use basal-bolus insulin regimen (NOT sliding scale alone) 1, 2
Start 0.3-0.5 units/kg/day total (50% basal, 50% prandial divided among meals) 2, 3
For high-risk patients (age >65, renal impairment, poor intake): 0.1-0.25 units/kg/day 2, 3

Steroid-Induced Hyperglycemia

Increase prandial and correction insulin by 40-60% in addition to basal insulin. 2

Monitoring Schedule

Glucose Monitoring:

Fasting glucose daily during insulin titration 2, 3
Pre-meal glucose for prandial insulin adjustment 2, 3
2-hour post-meal glucose to assess prandial adequacy 2, 3

HbA1c:

Every 3 months during intensive titration or when not meeting goals 1, 2
Every 6 months when stable and meeting goals 1

Common Pitfalls to Avoid

Therapeutic inertia: Do NOT delay medication intensification when HbA1c >7% for >3-6 months 1, 2
Over-basalization: Do NOT escalate basal insulin beyond 0.5-1.0 units/kg/day without adding prandial coverage 1, 2, 3
Discontinuing metformin: Continue metformin when adding insulin unless contraindicated 1, 2, 3
Ignoring cardiorenal protection: Prioritize SGLT2i/GLP-1 RA in patients with ASCVD/HF/CKD regardless of HbA1c 1, 2
Sliding scale monotherapy: NEVER use correction insulin alone; always provide scheduled basal ± prandial insulin 1, 2, 3

Summary Flowchart

DIAGNOSIS → Metformin + Lifestyle
              ↓ (3 months)
         HbA1c >7%?
              ↓ YES
    Add SGLT2i/GLP-1 RA (if ASCVD/HF/CKD)
    OR DPP-4i/SU (if no comorbidities)
              ↓ (3-6 months)
         HbA1c >7%?
              ↓ YES
    Add 3rd agent OR Basal Insulin
    (Continue metformin; stop SU if starting insulin)
              ↓
    Titrate basal insulin to 0.5 units/kg/day
              ↓
    If HbA1c still >7%:
    Add GLP-1 RA (preferred) OR Prandial Insulin

Key Principle: Prioritize cardiorenal protection with SGLT2i/GLP-1 RA early; avoid therapeutic inertia; individualize HbA1c targets based on patient factors. 1, 2

Create a concise inpatient and outpatient clinical practice guideline for managing type 2 diabetes mellitus according to current guidelines, presented in bullet points or flowchart format.

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