Polyuria, polydipsia; obesity/insulin resistance
Diagnose: A1c ≥6.5% · FPG ≥126 · random ≥200 + symptoms · OGTT ≥200 (confirm)
Start: Lifestyle (weight loss) → Metformin 500 mg PO → titrate to 2 g/day (best initial)
Add (esp. ASCVD/CKD/HF): GLP-1 RA or SGLT2 inhibitor
A1c very high / symptomatic → insulin
Order set
- Fasting glucose/HbA1c
- U&E, lipids
- Urine ACR
- Retinal + foot screen
Criteria
AdmitDKA/HHS or severe symptomatic hyperglycaemia
DischargeGlucose safe, education done, therapy + follow-up
Key
- Sulfonylureas cause weight gain & hypoglycemia. A1c goal <7% (individualize).
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
- Ketosis/weight loss (?type 1)
- Very high glucose with symptoms
Differentials
- Stress hyperglycaemia
- MODY
- Secondary diabetes
Common mistakes
- Sulfonylurea as default
- Missing type 1
Disposition & follow-up
Lifestyle + metformin; add SGLT2i/GLP-1 by risk; structured review.
Discharge package
MedicationsMetformin ± SGLT2i/GLP-1; individualised
Follow-upDiabetes team; HbA1c 3-monthly initially
VaccinationInfluenza, pneumococcal
LifestyleDiet, activity, weight, self-monitoring education
Warning symptomsVery high/low glucose, ketosis, infection; ketosis with NORMAL glucose on SGLT2i = euglycemic DKA — counsel sick-day rules at initiation (ADA 2026)
💊 Treatment detail — doses & preparation
Metforminbiguanide
Dose500 mg OD with food, ↑weekly to 1 g BD (max 2–3 g/day)
Preparation500/850/1000 mg tablets (MR available for GI upset)
MonitoreGFR (stop <30, caution <45), hold for contrast/acute illness, B12 annually
EmpagliflozinSGLT2 inhibitor
Dose10 mg OD
Preparation10/25 mg tablets
MonitorSick-day rules, volume status, eGFR
SemaglutideGLP-1 agonist
Dose0.25 mg SC weekly ×4 wk, then 0.5–1 mg weekly
PreparationPre-filled pen, SC abdomen/thigh; refrigerate
MonitorGI upset, pancreatitis warning, weight loss
Glimepiridesulfonylurea
Dose1–4 mg OD with breakfast
Preparation1/2/3/4 mg tablets
MonitorHypoglycaemia (esp. elderly/CKD), weight gain
📖 ADA Standards of CareReviewed July 2026