ADA · 2026

Type 2 Diabetes Mellitus — Standards of Care

Source: American Diabetes Association, Standards of Care in Diabetes — 2026

Guideline: Strong Guideline: Conditional Guideline: Not recommended ClinicoQ pathway suggestion (not from the cited guideline)

Diagnosis

Diagnostic criteria Diagnosed by any of: A1C ≥6.5%, fasting plasma glucose ≥126 mg/dL (after ≥8h fast), 2-hour plasma glucose ≥200 mg/dL during a 75g OGTT, or random plasma glucose ≥200 mg/dL with classic hyperglycemic symptoms. Without unequivocal hyperglycemia, confirm with a repeat abnormal result.

⚠ Alarm features (investigate before diagnosing)

Diabetic ketoacidosis (severe hyperglycemia, ketosis, acidosis)
Hyperosmolar hyperglycemic state
Unexplained rapid weight loss with hyperglycemia (consider type 1 diabetes or a secondary cause)
Active foot infection or ulceration
New visual disturbance (possible retinopathy)

Initial workup

Test	When to order
A1C	At diagnosis, then every 3–6 months to monitor control.
Fasting lipid panel	At diagnosis and periodically, to assess cardiovascular risk.
Urine albumin-to-creatinine ratio + eGFR	At diagnosis and annually, to screen for diabetic kidney disease.
Dilated eye exam	At diagnosis and annually, to screen for retinopathy.
Comprehensive foot exam	At diagnosis and annually.

Treatment

General (all patients)

1 Metformin + intensive lifestyle intervention Strong (Guideline recommendation)

Dose: Start 500 mg once or twice daily with meals; titrate over 1–2 weeks toward 1000 mg twice daily (max ~2000–2550 mg/day)
Duration: Ongoing
Evidence level: High
Avoid if: eGFR below 30 mL/min/1.73m²; acute risk of lactic acidosis (severe illness, IV contrast)
If no response ClinicoQ pathway: Add an SGLT2 inhibitor or GLP-1 receptor agonist based on the comorbidity profile below

With ASCVD, heart failure, or CKD

1 SGLT2 inhibitor (e.g., empagliflozin, dapagliflozin) Strong (Guideline recommendation) — added early, independent of metformin, for cardiorenal benefit

Dose: Per product labeling, once daily
Duration: Ongoing
Evidence level: High
Avoid if: Type 1 diabetes; recurrent genital mycotic infections; eGFR below the label threshold
If no response ClinicoQ pathway: Add or switch to a GLP-1 receptor agonist

2 GLP-1 receptor agonist (e.g., semaglutide, dulaglutide) Strong (Guideline recommendation) — cardiovascular benefit independent of glycemic goals

Dose: Per product labeling, weekly or daily depending on agent, with dose titration
Duration: Ongoing
Evidence level: High
Avoid if: Personal/family history of medullary thyroid carcinoma or MEN2; history of pancreatitis
If no response ClinicoQ pathway: Combine SGLT2i + GLP-1 RA, or add insulin if glycemic control remains inadequate

Insufficient control despite above

1 Basal insulin Strong (Guideline recommendation), when needed

Dose: Start ~10 units/day or 0.1–0.2 units/kg/day (ADA-recommended starting range), titrate to fasting glucose target
Duration: Ongoing
Evidence level: High
Avoid if: Hypoglycemia unawareness without adequate support/education in place
If no response ClinicoQ pathway: Add prandial insulin or refer to endocrinology

✕ Treatments the guideline advises against

Adding fibrate, niacin, or n-3 fatty acid supplements to statin therapy: Guideline advises against this — they do not confer additional cardiovascular risk reduction.

Sulfonylureas and thiazolidinediones as preferred agents: Guideline de-emphasizes these relative to SGLT2i/GLP-1 RA; associated with hypoglycemia, weight gain, and increased bone fracture risk — use with caution, particularly in older adults.

⚠️ This is an educational summary of current international clinical practice guidelines and does not replace individualized clinical judgment. Final treatment decisions remain the responsibility of the treating physician.