Endocrine · Topic 5 of 13

Type 2 Diabetes Management

Endocrine · diabetes management

Type 2 Diabetes Management

A1C under 7% for most; add an SGLT2 inhibitor or GLP-1 RA for ASCVD, heart failure or CKD regardless of A1C.

Key numbers

A1C goal < 7% for mostA1C < 7%

Heart failure or CKD: SGLT2 inhibitoreGFR ≥ 20

Start insulin if A1C > 10%A1C > 10%

Stop SGLT2 inhibitors 3 days before surgerystop 3 days pre-op

Metformin: no start below eGFR 45contraindicated eGFR < 30

01 · The numberA1C goal < 7% for most

A1C < 7% suits many nonpregnant adults; < 6.5% if reachable without hypoglycemia; up to 8% for limited life expectancy, frailty or high hypoglycemia risk.

02 · GiveASCVD: GLP-1 RA or SGLT2 inhibitor

With established or high-risk ASCVD, include a GLP-1 RA and/or SGLT2 inhibitor with proven cardiovascular benefit, regardless of A1C and with or without metformin.

03 · GiveHeart failure or CKD: SGLT2 inhibitor

Use an SGLT2 inhibitor for heart failure (HFrEF or HFpEF) and CKD with eGFR 20–60 and/or albuminuria; start if eGFR ≥ 20 (glucose lowering fades below 45). Semaglutide is the CKD alternative.

Causes & risk factors

Why it happens

Sulfonylureas: hypoglycemia and weight gainSulfonylureas cause hypoglycemia and 2–5 kg weight gain; use them cautiously in adults > 65, with kidney disease and with insulin.

Management

Orders

Start insulin if A1C > 10% must knowStart insulin, whatever else the patient takes, for A1C > 10%, glucose ≥ 300 mg/dL, symptomatic hyperglycemia or catabolic features (weight loss, ketosis); otherwise prefer a GLP-1–based drug before insulin.

Metformin: no start below eGFR 45Metformin is contraindicated at eGFR < 30 and should not be started at 30–45; it causes GI upset and vitamin B12 deficiency (check B12 periodically) but not hypoglycemia.

Sick days: hold metformin and SGLT2 inhibitorsConsider holding metformin and SGLT2 inhibitors when oral intake cannot be maintained or AKI is a concern; check ketones if unwell on an SGLT2 inhibitor.

Basal insulin starts at 0.1–0.2 U/kg/dayStart basal insulin at 0.1–0.2 U/kg/day and titrate to fasting glucose.

Obesity: semaglutide or tirzepatidePrioritize glucose-lowering drugs that cause weight loss; semaglutide and tirzepatide have the highest efficacy for both glucose and weight, and tirzepatide or a GLP-1 RA helps HFpEF with obesity.

Combination therapy if A1C 1.5–2% above goalStart pharmacotherapy at diagnosis; consider initial combination therapy when A1C is 1.5–2.0% above the individualized goal.

Hold GLP-1 RAs when acutely ill in hospitalHold GLP-1 RAs in acutely ill inpatients; manage them perioperatively case by case (aspiration risk from delayed gastric emptying).

Metformin first-line when no comorbidity drives choiceMetformin (effective, safe, inexpensive) remains the usual first agent when only glucose lowering guides the choice; ASCVD, heart failure or CKD call for an SGLT2 inhibitor or GLP-1 RA, with or without metformin.

Red flags & don'ts

Avoid harm

Stop SGLT2 inhibitors 3 days before surgery avoidStop SGLT2 inhibitors 3 days before scheduled surgery (4 days for ertugliflozin) to prevent euglycemic DKA; hold metformin and other oral agents on the day of surgery.

GLP-1 RA: no MTC or MEN2 history avoidGLP-1 RAs are contraindicated with a personal or family history of medullary thyroid carcinoma or MEN2; they slightly raise pancreatitis risk — stop them if pancreatitis is suspected.

No pioglitazone in heart failure avoidPioglitazone causes fluid retention and raises heart-failure risk — do not use it in heart failure.

SGLT2 inhibitors: genital infection, euglycemic DKA complicationSGLT2 inhibitors cause genital mycotic infections and UTIs, volume depletion and orthostasis, euglycemic DKA (diagnosis often delayed) and, rarely, Fournier gangrene.

SGLT2 inhibitor or GLP-1 RA?

Commonly confused

Signature benefit	Heart failure and CKD (plus ASCVD)
Weight	Modest loss
Key risks	Genital infection, volume depletion, euglycemic DKA
Contraindication	Not for type 1 diabetes
Before surgery	Stop 3 days ahead

More detail

Reference

Show 4 reference facts

With MASLD or MASH, a GLP-1 RA with liver benefit is preferred for glucose lowering; pioglitazone or tirzepatide can be considered for their potential MASH benefit.

Temporarily stop metformin before radiologic procedures using iodinated contrast, especially with reduced kidney function.

For CGM users, aim for time in range (70–180 mg/dL) above 70% with less than 4% below 70 mg/dL.

SGLT2 inhibitors raise DKA risk 5–17-fold in type 1 diabetes and are not approved for it in the US.

Pearl

Pick the drug for the organ: heart failure and kidneys → SGLT2; weight and liver → GLP-1; arteries → either.

Sources · ADA. 6. Glycemic Goals, Hypoglycemia, and Hyperglycemic Crises: Standards of Care in Diabetes—2026. Diabetes Care 2026;49(Suppl 1) · ADA. 9. Pharmacologic Approaches to Glycemic Treatment: Standards of Care in Diabetes—2026. Diabetes Care 2026;49(Suppl 1) · Merck Manual Professional — Medications for Diabetes Mellitus Treatment · ADA. 16. Diabetes Care in the Hospital: Standards of Care in Diabetes—2026. Diabetes Care 2026;49(Suppl 1) · Umpierrez GE et al. Hyperglycemic Crises in Adults With Diabetes: A Consensus Report (ADA/EASD/JBDS/AACE/DTS). Diabetes Care 2024;47:1257–1275 (also Diabetologia 2024) · Semaglutide tablets (Ozempic/Rybelsus) prescribing information — DailyMed (contraindications) · Starter sheet built from the verified AGACNP fact map (facts reviewed 2026-10-15).