Type 2 diabetes in adults

Red Flags

Hyperglycaemic emergency: DKA, HHS, severe hypoglycaemia — emergency department; IV fluids, insulin, electrolyte correction^[1]
T2DM with established CVD or high CV risk not on SGLT2 inhibitor or GLP-1 RA — guideline-discordant; initiate at next visit^[1]
T2DM with new heart failure or CKD — initiate SGLT2 inhibitor regardless of HbA1c; cardio-renal protection independent of glycaemic effect^[1]
Severe hypoglycaemia in elderly or frail — relax HbA1c target to <8% or individualised; reduce insulin/sulfonylurea^[1]

First-line treatment

Interventions

Holistic person-centred care^[1]
ADA/EASD framework: cardiovascular risk reduction is the primary objective alongside glycaemic management; weight, BP, lipids, lifestyle, mental health all addressed simultaneously
Lifestyle: diet, activity, sleep, smoking, alcohol^[1]
Mediterranean / DASH / low-carbohydrate diet; 5–10% weight loss target; ≥150 min/week aerobic activity; smoking cessation
Annual complications surveillance^[1]
Eye, foot, kidney, cardiovascular, mental health, dental, sexual function screening annually

First-line drug therapy

Drug	Class	Adult	Paediatric	Notes
Metformin^[1]	Biguanide	500 mg PO daily, titrate to 1 g BD; max 2 g/day; avoid if eGFR <30	—	Foundation therapy unless contraindicated; combine from outset with SGLT2i or GLP-1 RA in high-CV-risk patients
Empagliflozin or dapagliflozin^[1]	SGLT2 inhibitor	Empagliflozin 10–25 mg or dapagliflozin 10 mg PO once daily	—	Class I in ASCVD, HF, or CKD regardless of HbA1c; consider in stage 3 CKD with eGFR ≥20
Semaglutide or tirzepatide^[1]	GLP-1 receptor agonist or GIP/GLP-1 agonist	Semaglutide 0.25 mg SC weekly titrate to 1–2 mg; tirzepatide 2.5 mg SC weekly titrate to 5–15 mg	—	Class I in ASCVD; significant weight reduction; tirzepatide superior glycaemic and weight effect per SURPASS
Sulfonylurea (glimepiride or gliclazide)^[1]	Insulin secretagogue	Glimepiride 1–4 mg PO daily; gliclazide 30–120 mg PO daily (SR)	—	Cost-effective add-on when SGLT2i/GLP-1 unavailable; hypoglycaemia and weight gain risks
Basal insulin (glargine, degludec)^[1]	Long-acting insulin analogue	0.1–0.2 U/kg once daily; titrate by 2 units every 3 days to fasting glucose target	—	Add when oral therapies + GLP-1 fail; basal-only often sufficient for years before basal-bolus

Metformin^[1]

Biguanide

Adult: 500 mg PO daily, titrate to 1 g BD; max 2 g/day; avoid if eGFR <30
Paediatric: —

Foundation therapy unless contraindicated; combine from outset with SGLT2i or GLP-1 RA in high-CV-risk patients

Empagliflozin or dapagliflozin^[1]

SGLT2 inhibitor

Adult: Empagliflozin 10–25 mg or dapagliflozin 10 mg PO once daily
Paediatric: —

Class I in ASCVD, HF, or CKD regardless of HbA1c; consider in stage 3 CKD with eGFR ≥20

Semaglutide or tirzepatide^[1]

GLP-1 receptor agonist or GIP/GLP-1 agonist

Adult: Semaglutide 0.25 mg SC weekly titrate to 1–2 mg; tirzepatide 2.5 mg SC weekly titrate to 5–15 mg
Paediatric: —

Class I in ASCVD; significant weight reduction; tirzepatide superior glycaemic and weight effect per SURPASS

Sulfonylurea (glimepiride or gliclazide)^[1]

Insulin secretagogue

Adult: Glimepiride 1–4 mg PO daily; gliclazide 30–120 mg PO daily (SR)
Paediatric: —

Cost-effective add-on when SGLT2i/GLP-1 unavailable; hypoglycaemia and weight gain risks

Basal insulin (glargine, degludec)^[1]

Long-acting insulin analogue

Adult: 0.1–0.2 U/kg once daily; titrate by 2 units every 3 days to fasting glucose target
Paediatric: —

Add when oral therapies + GLP-1 fail; basal-only often sufficient for years before basal-bolus

Safety-net

Recognise hypoglycaemia and carry rapid-acting carbohydrate; severe episodes need urgent care^[1]
Sick-day rules: continue insulin and metformin unless dehydrated; pause SGLT2 inhibitor with vomiting or dehydration^[1]
Annual eye and foot screening prevents blindness and amputation — never skip these even when feeling well^[1]

Referral criteria

DKA, HHS, or severe hypoglycaemiaEmergency department / ICU^[1]
T2DM in pregnancy or planning pregnancyJoint diabetes-obstetric care^[1]
Established ASCVD, HF, or CKD without SGLT2i or GLP-1 RADiabetes specialist for therapy intensification^[1]
HbA1c >10% at diagnosis or symptomatic hyperglycaemiaDiabetes specialist; consider initial insulin^[1]

Clinical summary

ADA/EASD consensus on holistic, person-centred glycaemic and cardiometabolic management of T2DM with cardio-renal protection emphasised over HbA1c-only target.

References

1.ADA/EASD 2022 Consensus Report — Management of Hyperglycemia in Type 2 Diabetes (ongoing as living standard); ADA Standards of Care 2026 (2022)