T2DM

#T2DM, established, ***controlled
Diagnosed (year). Last A1c: *** (q3-6 months), goal: <7 (FBG 70-130, postprandial <180) [<8 in elderly/low life expectancy, high risk of hypoglycemia]. Complicated by ***. Aim for aggressive early control to prevent micro/macrovascular complications--leading cause of death is ASCVD.
Changes today: ***
- Medications
-- non insulin therapies:
--- uptitrate metformin to 1g BIDAC by 500mg qweek to minimize GI side effects (caution GFR 30-45); consider B12 supplementation
--- GLP/SGLT if ASCVD
--- SGLT2 if HF/CKD
--- DPP4/GLP/SGLT if c/f hypoglycemia
--- GLP/SGLT if weight loss
--- SU/TZD if cost concern
-- insulin: (consider if initial A1c>10 or not at goal on 3 agents)
-- statin/ASA/ACEi: (consider ASA if ASCVD risk >10%)
-- FSBS frequency: (regular checks not necessary unless on insulin)
- Non-medication therapies
-- Diet/Nutritionist: low-carb or mediteranean
-- Exercise:
-- Weight loss: (goal 5-10% for obese; consider bariatic surgery if BMI>35)
-- DM Education date:
- Monitoring/prevention
-- Microalbuminuria (annual):
-- Blood Pressure < 130/80:
-- Statin: moderate/high intensity, ? LDL goal <100
-- Foot Exam (annual):
-- Podiatry (y/n):
-- Ophthalmology (annual):
-- Flu shot (annual):
-- Pneumovax (before age 65, boost after):
-- Hypoglycemia risk:
- Workup if young, thin, fam/personal hx autoimmune dz, hyperglycemia despite PO agents, h/o DKA
-- send GAD, ICA, IA2, insulin autoab
-- consider hemochromatosis, CF-related, pancreatic CA, cushings, chronic pancreatitis

https://care.diabetesjournals.org/content/diacare/42/Supplement_1/S90/F1.large.jpg