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T2DM ADA2026 Presentation
Presentation · PPTX

What's Inside — 14 Slides

Slide	Content
1	Title — Type 2 Diabetes Mellitus · ADA 2026
2	Overview — Definition, global burden, 5 pathophysiologic pillars (insulin resistance, β-cell dysfunction, glucotoxicity, incretin defect)
3	Classification — ADA 2026 four categories with T2DM highlighted; AABBCC differentiation tool
4	Diagnostic Criteria + Flowchart — Table 2.1 (A1C/FPG/OGTT/random PG thresholds), prediabetes values, who-to-screen flowchart, key risk factors
5	Labs & Monitoring — Initial workup list, full glycemic targets table (A1C, TIR, TBR, GMI), CGM vs BGM guidance
6	Non-Pharmacologic Treatment — MNT, physical activity guidelines, DSMES, weight management
7	Pharmacologic Algorithm — 3-step ADA 2026 algorithm; comorbidity-driven agent selection
8	Drug Classes Table — Metformin, SGLT2i, GLP-1 RA, dual GIP/GLP-1 (tirzepatide), DPP-4i, SU, TZD, insulin — efficacy/weight/CV/kidney/AEs
9	Pharmacologic Contraindications — Drug-specific CIs with red warning formatting
10	Non-Pharmacologic Contraindications — Exercise, dietary, surgical, behavioral precautions
11	Follow-Up Schedule — 11-parameter monitoring table + complication targets + vaccines
12	Special Populations — ASCVD, CKD, elderly, obesity, heart failure, pregnancy
13	Key Takeaways — 8 numbered clinical pearls
14	References — All 11 ADA 2026 sections cited

The design uses a deep navy / teal / gold palette with section banners, color-coded info boxes, and a widescreen (13.3" × 7.5") format — similar in style to your osteoporosis template.

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Here is your full 20-slide Type 2 Diabetes Mellitus presentation based on the ADA Standards of Care 2026, delivered directly in chat:

🩺 TYPE 2 DIABETES MELLITUS

A Comprehensive Clinical Presentation

ADA Standards of Care in Diabetes — 2026 Diabetes Care 2026;49(Suppl. 1)

SLIDE 1 — TITLE SLIDE

Type 2 Diabetes Mellitus

ADA Standards of Care 2026

Topic Presenter: [Your Name] Course/Rotation: [Course Name] Date: June 2026

"Diabetes is a complex, chronic condition requiring continuous care with comprehensive risk-reduction strategies beyond glycemic management." — ADA Standards of Care, 2026

SLIDE 2 — OVERVIEW: What Is Type 2 Diabetes?

Definition

Type 2 diabetes (T2DM) accounts for 90–95% of all diabetes cases. It encompasses individuals who have a relative (rather than absolute) insulin deficiency in association with insulin resistance — a decreased biological response to insulin signals.

At a Glance

Feature	T2DM
% of all DM	90–95%
Onset	Often insidious / asymptomatic for years
Primary defect	Insulin resistance + progressive β-cell dysfunction
Immune-mediated?	❌ No (non-autoimmune)
DKA risk	Rare; occurs with stress, illness, SGLT2i
HHS risk	✅ Yes — more typical of T2DM

Why It Matters

537 million adults living with diabetes worldwide (IDF 2021)
Prevalence rising dramatically in children and adolescents
Often undiagnosed for years → macro- and microvascular complications accumulate silently
Duration of glycemic burden is a strong predictor of adverse outcomes

Source: ADA 2026, Section 2 (S27–S49)

SLIDE 3 — PATHOPHYSIOLOGY OF T2DM

The "Ominous Octet" (Adapted)

T2DM results from multiple converging defects:

1. 🔴 Insulin Resistance

Skeletal muscle, liver, and adipose tissue fail to respond normally to insulin
Most prominent in obesity — especially abdominal/visceral adiposity

2. 🔵 Progressive β-cell Dysfunction

Genetic predisposition + epigenetic changes + metabolic stress → β-cell exhaustion
β-cell mass declines over time

3. 🟡 Relative Insulin Deficiency

Initially hyperinsulinemia to compensate → failing compensation → frank hyperglycemia

4. 🟢 Glucotoxicity & Lipotoxicity

Chronic hyperglycemia + elevated free fatty acids worsen β-cell function (vicious cycle)

5. 🟣 Incretin Defect

Reduced GLP-1 and GIP response to meals → impaired postprandial insulin secretion

6. ⚪ Increased Hepatic Glucose Production

Inappropriate gluconeogenesis and glycogenolysis despite hyperglycemia

7. 🟤 Impaired Renal Glucose Reabsorption

Kidneys reabsorb ~180g glucose/day; threshold elevated in T2DM

8. ⚫ Abnormal α-cell Function

Inappropriately elevated glucagon → drives hepatic glucose output

Source: ADA 2026, Section 2 & 9; Skyler et al., Diabetes 2017

SLIDE 4 — CLASSIFICATION OF DIABETES (ADA 2026)

Four Main Categories (Rec 2.5)

Category	Key Features
Type 1 DM	Autoimmune β-cell destruction → absolute insulin deficiency (incl. LADA)
⭐ Type 2 DM	Non-autoimmune, progressive β-cell failure + insulin resistance; 90–95% of all cases
Gestational DM (GDM)	Diagnosed in 2nd/3rd trimester; not overt DM prior to pregnancy
Other Specific Types	Monogenic (MODY, neonatal DM), pancreatic disease (Type 3c), drug-induced, post-transplant (PTDM)

Differentiating T1 vs T2 — the AABBCC Tool

When diabetes type is unclear, use:

Age — age <35 yrs: favor T1DM
Autoimmunity — personal/family Hx of autoimmune disease
Body habitus — BMI <25 kg/m²: favor T1DM
Background — family Hx of T1DM
Control — inability to achieve glycemic goals on non-insulin agents
Comorbidities — e.g., immune checkpoint inhibitor therapy → acute autoimmune DM

⚠️ Important Note

Misclassification occurs in up to 40% of adults with new T1DM
T2DM with DKA possible — especially in Black and Hispanic/Latino adults (ketosis-prone diabetes)

Source: ADA 2026, Section 2 (S30–S36); Holt et al., Diabetes Care 2021

SLIDE 5 — DIAGNOSTIC CRITERIA (ADA 2026, Table 2.1)

Criteria for Diagnosis of Diabetes (Nonpregnant Individuals)

Test	Diabetes Threshold	Notes
A1C	≥ 6.5% (≥48 mmol/mol)	NGSP-certified, DCCT-standardized lab
Fasting Plasma Glucose (FPG)	≥ 126 mg/dL (≥7.0 mmol/L)	Fasting = no caloric intake ≥8 hours
2-h PG (75g OGTT)	≥ 200 mg/dL (≥11.1 mmol/L)	WHO protocol; 150g carbs x 3 days prior
Random Plasma Glucose	≥ 200 mg/dL (≥11.1 mmol/L)	+ classic symptoms of hyperglycemia OR hyperglycemic crisis

Confirmation Rule

In the absence of unequivocal hyperglycemia: diagnosis requires 2 abnormal results from the same or different tests (same visit or 2 different time points).

Prediabetes Criteria (Table 2.2)

Test	Prediabetes Range
A1C	5.7–6.4% (39–47 mmol/mol)
FPG	100–125 mg/dL → Impaired Fasting Glucose (IFG)
2-h PG (OGTT)	140–199 mg/dL → Impaired Glucose Tolerance (IGT)

A1C Limitations — When to Use Plasma Glucose Instead:

Hemoglobin variants (sickle cell trait)
Conditions altering RBC turnover (anemia, hemolysis, G6PD deficiency)
HIV, cirrhosis, CKD, pregnancy
Iron deficiency (falsely elevates A1C)

Source: ADA 2026, Section 2 (S27–S29)

SLIDE 6 — SCREENING: WHO, WHEN, & HOW

Who to Screen (Table 2.5) — Asymptomatic Adults

Screen at ANY age if overweight/obese (BMI ≥25, or ≥23 in Asian individuals) PLUS ≥1 of:

First-degree relative with diabetes
High-risk race/ethnicity (African American, Latino, Native American, Asian American)
History of cardiovascular disease
HTN ≥130/80 mmHg (or on antihypertensive therapy)
HDL <35 mg/dL AND/OR triglycerides >250 mg/dL
Polycystic ovary syndrome (PCOS)
Physical inactivity
Acanthosis nigricans, MASLD, severe obesity

Screen ALL adults regardless of weight starting at age 35

Special groups to screen:

Prior GDM → every 1–3 years (Rec 2.33–2.34)
Prediabetes → annually
On glucocorticoids, statins, thiazides, HIV meds, antipsychotics → screen at initiation
HIV: FPG before ARV, at switch, and 3–6 months after (Rec 2.17)

Testing Interval

Normal results → repeat every 3 years minimum (sooner if weight gain or new risk factors)

Screening Tools

FPG, A1C, or 2-h OGTT are each appropriate (Rec 2.13)
ADA Risk Test online: diabetes.org/diabetes-risk-test

Source: ADA 2026, Section 2 (S34–S38)

SLIDE 7 — DIAGNOSTIC FLOWCHART FOR T2DM

┌──────────────────────────────────────────────────┐
│         ASYMPTOMATIC ADULT PRESENTING             │
│         FOR ROUTINE CARE OR SCREENING             │
└─────────────────────┬────────────────────────────┘
                      │
                      ▼
┌──────────────────────────────────────────────────┐
│  STEP 1: RISK ASSESSMENT                         │
│  • Age ≥35 years?              → SCREEN          │
│  • Overweight/obese + ≥1 RF?   → SCREEN          │
│  • Prediabetes / prior GDM?    → SCREEN ANNUALLY │
│  • No risk factors, age <35?   → ROUTINE CARE    │
└─────────────────────┬────────────────────────────┘
                      │
                      ▼
┌──────────────────────────────────────────────────┐
│  STEP 2: DIAGNOSTIC TEST                         │
│  Choose: FPG or A1C (preferred outpatient)       │
│          OR 2-h 75g OGTT (most sensitive)        │
└──────────┬───────────────────┬───────────────────┘
           │                   │
           ▼                   ▼
    ┌─────────────┐      ┌──────────────┐
    │  NORMAL     │      │  PREDIABETES │
    │  FPG <100   │      │  A1C 5.7–6.4%│
    │  A1C <5.7%  │      │  FPG 100–125 │
    │             │      │  2-h 140–199 │
    │ Repeat in   │      │              │
    │  3 years    │      │ Lifestyle Rx │
    └─────────────┘      │ Metformin    │
                         │ Retest yearly│
                         └──────┬───────┘
                                │
                                ▼
                    ┌────────────────────────┐
                    │  DIABETES (T2DM)       │
                    │  A1C ≥6.5%            │
                    │  FPG ≥126 mg/dL       │
                    │  2-h PG ≥200          │
                    │  Random ≥200 + Sx     │
                    │                       │
                    │ ⚠️ Confirm with 2nd   │
                    │  test (no Sx crisis)  │
                    └────────────────────────┘
                                │
                                ▼
                    ┌────────────────────────┐
                    │ CLASSIFY TYPE         │
                    │ Use AABBCC tool       │
                    │ Check islet Ab if T1  │
                    │ suspicious            │
                    │ → Start Treatment     │
                    └────────────────────────┘

Source: ADA 2026, Section 2; Rec 2.1–2.15

SLIDE 8 — LABORATORY EVALUATION

Initial Workup at T2DM Diagnosis

Lab Test	Rationale
A1C (NGSP-certified)	Baseline glycemic control; confirms diagnosis
Fasting lipid panel	LDL-C, HDL-C, TG, Total cholesterol — CV risk
Serum creatinine + eGFR	Baseline kidney function; CKD screening
Urine albumin-to-creatinine ratio (UACR)	Early nephropathy detection
Liver function tests (ALT/AST)	MASLD screening; pre-metformin baseline
TSH	Thyroid disease associated with DM
Vitamin B12	Baseline if starting metformin
Blood pressure	Every visit; goal <130/80 mmHg
BMI + weight	Every visit
Foot exam (monofilament)	Baseline neuropathy screening
Dilated fundus exam	Baseline retinopathy screening

Glycemic Monitoring Options

Method	Measurement	When to Prefer
A1C	2–3 month average glucose	Standard monitoring
CGM — TIR	% time 70–180 mg/dL	Preferred if on insulin or frequent hypoglycemia
CGM — TBR	% time <70 mg/dL	Key safety metric
BGM (fingerstick)	Point-in-time glucose	Adjunct; cost-effective
Fructosamine / Glycated albumin	~2–3 week average	When A1C unreliable (hemoglobinopathy, hemolysis, CKD, pregnancy)

Source: ADA 2026, Sections 4 & 6 (S61–S149)

SLIDE 9 — GLYCEMIC TARGETS (ADA 2026, Section 6)

Standard A1C Goals

Population	A1C Target
Most non-pregnant adults	< 7.0% (<53 mmol/mol)
Younger adults, recently diagnosed, long life expectancy, no hypoglycemia	< 6.5% if achievable safely
Older adults, frail, limited life expectancy, high hypoglycemia risk	< 8.0–8.5%
Pregnancy (preconception)	< 6.0–6.5%

CGM-Based Glycemic Targets

CGM Metric	Target (Standard)	Modified Target (Elderly/High-Risk)
Time in Range (TIR) 70–180 mg/dL	> 70%	> 50%
Time Below Range (TBR) < 70 mg/dL	< 4%	< 1%
Critical Low < 54 mg/dL	< 1%	< 1%
Time Above Range (TAR) >180 mg/dL	< 25%	—
GMI (Glucose Management Indicator)	Correlates with A1C target	—

BGM (Fingerstick) Targets

Pre-meal: 80–130 mg/dL
Peak postprandial (1–2 hrs): < 180 mg/dL

Key Principle

Individualize! Tighter control in young, newly diagnosed. Relaxed goals in frail elderly, dementia, recurrent severe hypoglycemia, limited life expectancy, or when burdensome to achieve.

Assess glycemic status at least 2x/year (stable at goal) or every 3 months (not at goal or medication changes)

Source: ADA 2026, Section 6 (S132–S149); Recs 6.1–6.6

SLIDE 10 — NON-PHARMACOLOGIC TREATMENT

1. Medical Nutrition Therapy (MNT)

Goal: 5–10% weight reduction → meaningful glycemic improvement (≥15% → possible remission)
No single optimal eating pattern — evidence supports:
- Mediterranean diet ✅
- DASH diet ✅
- Low-carbohydrate diet ✅
- Plant-based diet ✅
Reduce: refined carbs, added sugars, ultra-processed foods, sodium (<2,300 mg/day)
Increase: dietary fiber (vegetables, legumes, whole grains)
Limit alcohol — risk of hypoglycemia with insulin/SU
Refer to registered dietitian for individualized MNT counseling

2. Physical Activity

Aerobic: ≥150 min/week moderate-intensity (brisk walking, cycling, swimming)
Resistance training: ≥2 days/week — improves insulin sensitivity
Break prolonged sitting every 30 minutes
Benefits: A1C ↓ ~0.5–1.0%, weight loss, BP ↓, lipid improvement
⚠️ Pre-exercise glucose check if on insulin or sulfonylurea

3. DSMES — Diabetes Self-Management Education & Support

Recommended at: diagnosis, annually, when complicating factors arise, care transitions
ADA-recognized or CDC-recognized DPP programs
Covers: self-monitoring, medication management, foot care, sick-day rules, hypoglycemia rescue
Address social determinants of health (SDOH): food security, housing, access

4. Tobacco & Alcohol Cessation

Smoking cessation at every visit — smoking worsens CV risk and glycemia
Alcohol: moderate use only; do not drink on empty stomach (hypoglycemia risk with SU/insulin)

Source: ADA 2026, Sections 5 & 8

SLIDE 11 — PHARMACOLOGIC TREATMENT ALGORITHM

ADA 2026 — Step-by-Step Approach

🟦 STEP 1 — At Diagnosis (All T2DM)

✅ Metformin (unless contraindicated)
✅ Lifestyle modification (MNT + physical activity)
✅ DSMES referral
✅ Start pharmacotherapy immediately — do not delay

🟩 STEP 2 — Comorbidity-Driven Add-On Therapy (When A1C not at goal, or to address comorbidities)

Clinical Priority	Preferred Agent
Established ASCVD or high CV risk	GLP-1 RA (sema, lira, dula) or SGLT2i (empa, cana, dapa)
Heart failure (HFrEF or HFpEF)	SGLT2 inhibitor (empa, cana, dapa)
Chronic kidney disease	SGLT2i + consider GLP-1 RA; add finerenone if albuminuria
Need weight loss	GLP-1 RA or dual GIP/GLP-1 RA (tirzepatide)
Minimize hypoglycemia	DPP-4i, GLP-1 RA, SGLT2i
Cost concern	Sulfonylurea, TZD, NPH insulin

🟥 STEP 3 — Severe Hyperglycemia (A1C >10% OR glucose ≥300 mg/dL OR symptomatic)

Initiate insulin (basal insulin preferred)
GLP-1 RA + insulin combination preferred over insulin alone (Rec 9.22)
↓ SU/meglitinide dose when adding insulin (Rec 9.17)
Reassess and deintensify once glucose controlled

⚡ Rec 9.21: GLP-1 based therapy is preferred over insulin for most T2DM patients not in hyperglycemic crisis

Source: ADA 2026, Section 9 (S183–S215); Recs 9.15–9.23

SLIDE 12 — PHARMACOLOGY: DRUG CLASSES IN DETAIL

Metformin

MOA: ↓ hepatic glucose output; ↑ insulin sensitivity (AMPK activation)
Efficacy: High (A1C ↓ ~1.0–1.5%)
Hypoglycemia risk: None
Weight effect: Neutral (modest weight loss possible)
Key AEs: GI (nausea, diarrhea, bloating) — mitigate with slow titration, ER formulation, give with food; Vitamin B12 deficiency (monitor annually if on ≥4 yrs)
CI: eGFR <30; active hepatic disease; alcohol abuse; iodinated contrast (hold 48h)

SGLT2 Inhibitors (empagliflozin, canagliflozin, dapagliflozin, ertugliflozin)

MOA: Block SGLT2 in proximal tubule → glucosuria (150g glucose/day excreted)
Efficacy: Intermediate–High (A1C ↓ ~0.5–1.0%)
CV: ↓ MACE (empa, cana), ↓ HF hospitalization (empa, cana, dapa, ertu), ↓ CKD progression
Weight: Moderate loss (~2–3 kg)
Key AEs: Genital mycotic infections, UTI/urosepsis, DKA (rare in T2DM), Fournier's gangrene (rare), volume depletion
CI: eGFR <20 for glucose lowering; T1DM (↑ DKA risk); recurrent UTI; hold 3–4 days pre-surgery

GLP-1 Receptor Agonists (semaglutide, liraglutide, dulaglutide, exenatide)

MOA: Mimic GLP-1 → ↑ glucose-dependent insulin release, ↓ glucagon, ↓ gastric emptying, ↑ satiety
Efficacy: High–Very High (A1C ↓ ~1.0–1.8%); semaglutide highest
CV: ↓ MACE (sema SQ/oral, lira, dula); ↓ albuminuria; sema SQ → ↓ CKD progression
Weight: Moderate–High loss (5–10% body weight)
Key AEs: Nausea/vomiting/diarrhea, pancreatitis (rare), biliary disease, delayed gastric emptying, NAION (rare)
CI: Personal/family Hx medullary thyroid carcinoma (MTC); MEN-2; high pancreatitis risk; hold before procedures with general anesthesia

Dual GIP/GLP-1 RA — Tirzepatide

MOA: Dual agonist — activates both GIP and GLP-1 receptors
Efficacy: Very High (A1C ↓ ~2.0–2.4% in trials; highest of any non-insulin agent)
Weight: Very high loss (up to ~22% in SURMOUNT trials)
CV: Under investigation (SURPASS-CVOT ongoing); HF benefit shown (tirzepatide)
Key AEs: Same GI profile as GLP-1 RA; same thyroid/pancreatitis precautions

DPP-4 Inhibitors (sitagliptin, saxagliptin, alogliptin, linagliptin)

MOA: Inhibit DPP-4 enzyme → prevent GLP-1/GIP degradation → ↑ incretin effect
Efficacy: Moderate (A1C ↓ ~0.5–0.8%)
Weight: Neutral
Key AEs: Pancreatitis (rare); saxagliptin/alogliptin → ↑ HF hospitalization risk
CI: Hx of pancreatitis (caution); dose-adjust for CKD (except linagliptin)

Sulfonylureas (glipizide, glimepiride, glyburide/glibenclamide)

MOA: Stimulate pancreatic β-cell insulin release (ATP-sensitive K+ channel closure)
Efficacy: High (A1C ↓ ~1.0–1.5%)
Hypoglycemia risk: ⚠️ HIGH — most common serious AE
Weight: Gain (~2 kg)
Key AEs: Hypoglycemia (especially glibenclamide in elderly/CKD), weight gain
CI: CKD (↑ hypoglycemia — prefer glipizide); elderly; pregnancy (use insulin)

Thiazolidinediones / TZD (pioglitazone)

MOA: PPARγ agonist → ↑ adipose tissue insulin sensitivity; ↑ hepatic and muscle glucose uptake
Efficacy: High (A1C ↓ ~0.8–1.4%); durable effect
CV: Pioglitazone has CV benefit (PROactive trial)
Key AEs: Fluid retention/edema, weight gain, ↑ fracture risk (especially in women), bladder cancer risk (pioglitazone)
CI: HF (NYHA Class III/IV) — absolute; bladder cancer Hx; osteoporosis; pregnancy

Insulin

Types: Rapid (lispro, aspart, glulisine), Ultra-rapid (URAA), Short (regular), Intermediate (NPH), Long-acting (glargine U-100/U-300, detemir, degludec)
Efficacy: Highest — no ceiling effect
Hypoglycemia risk: ⚠️ HIGH
Weight: Gain
Key considerations: Adjust dose with exercise, illness, fasting; ↓ SU when adding insulin; GLP-1 RA + insulin preferred over insulin alone (Rec 9.22)

Source: ADA 2026, Section 9, Table 9.2

SLIDE 13 — PHARMACOLOGIC CONTRAINDICATIONS

Quick Reference Table

Drug Class	Absolute Contraindications	Major Precautions
Metformin	eGFR <30 mL/min/1.73m²	eGFR 30–45: use with caution; hold with contrast/surgery
SGLT2 Inhibitors	T1DM (↑ DKA risk)	eGFR <45 (↓ glucose-lowering efficacy, continue for CV/renal benefit if eGFR >20); hold 3–4 days pre-surgery
GLP-1 RA / Tirzepatide	Personal/family Hx MTC or MEN-2	High pancreatitis risk; severe GI motility disorder; hold before anesthesia/deep sedation
DPP-4 Inhibitors	Hx pancreatitis (relative)	Saxagliptin/alogliptin in HF; dose-adjust for CKD (not linagliptin)
Sulfonylureas	Pregnancy (use insulin)	CKD (especially glibenclamide → severe hypoglycemia); elderly frail patients
TZDs (pioglitazone)	HF NYHA III/IV; active/prior bladder cancer	Osteoporosis/fracture risk; liver disease; edema-prone patients
Insulin	No absolute CI	Hypoglycemia unawareness; must ↓ SU/meglitinide dose when adding

⚠️ Drug Combinations to Avoid

DPP-4i + GLP-1 RA: No additive benefit; not recommended (Rec 9.18)
TZD + Insulin: ↑ fluid retention + edema → ↑ HF risk
Glibenclamide in elderly or CKD: Prolonged severe hypoglycemia

Source: ADA 2026, Section 9, Table 9.2

SLIDE 14 — NON-PHARMACOLOGIC CONTRAINDICATIONS & PRECAUTIONS

Exercise / Physical Activity — When to Defer or Modify

Condition	Precaution
BG >300 mg/dL (or >250 with ketones)	Defer vigorous exercise — stabilize glycemia first
Recent DKA or HHS	Stabilize fully before resuming
Severe proliferative diabetic retinopathy	Avoid high-intensity or jarring activities (vitreous hemorrhage risk)
Peripheral neuropathy / active foot ulcer	Prefer non-weight-bearing exercise (swimming, cycling, water aerobics)
Autonomic neuropathy	Orthostatic hypotension risk; cardiac screening before vigorous program
On insulin or sulfonylurea	Carry fast-acting carbohydrate; check BG pre/during/post-exercise
Recent MI / unstable angina	Cardiology clearance before vigorous activity

Dietary / Nutrition Precautions

Intervention	Caution
Very low carbohydrate diet (<50g/day)	↓ insulin/SU dose to prevent hypoglycemia; monitor closely
Extended fasting / time-restricted eating	Must coordinate with insulin dosing; not recommended without monitoring
High protein intake	Restrict in advanced CKD — consult renal dietitian
Alcohol use	Risk of hypoglycemia with SU/insulin; no drinking on empty stomach
Post-bariatric surgery	Risk of dumping syndrome, hypoglycemia, nutritional deficiencies (B12, iron, Ca²⁺, vitamin D)

Metabolic / Bariatric Surgery — Contraindications

Active substance use disorder
Unstable psychiatric conditions (uncontrolled depression, psychosis, active suicidality)
Inability to comply with post-op follow-up and lifelong nutritional supplementation
Active malignancy (relative)
Pregnancy (relative)

Source: ADA 2026, Sections 5 & 8

SLIDE 15 — MANAGEMENT OF COMORBIDITIES

Cardiovascular Disease & Risk Management (Section 10)

ASCVD / High CV Risk:

GLP-1 RA with proven MACE benefit: semaglutide SQ (SUSTAIN-6), semaglutide oral (SOUL), liraglutide (LEADER), dulaglutide (REWIND)
SGLT2i with proven HF benefit: empagliflozin (EMPA-REG), canagliflozin (CANVAS), dapagliflozin (DECLARE)
Statin (high-intensity if ASCVD); ACEi or ARB (if albuminuria or HTN)
Aspirin 75–100 mg/day: established CVD (not routine primary prevention)

BP Target: <130/80 mmHg (most T2DM adults)

First-line antihypertensives: ACEi/ARB (especially with albuminuria), CCB, thiazide

Lipid Target:

ASCVD: LDL-C <70 mg/dL; consider ezetimibe/PCSK9i if not at goal
No ASCVD: LDL-C <100 mg/dL

Chronic Kidney Disease (Section 11)

SGLT2i (eGFR >20): slows CKD progression — continue until dialysis or transplant
GLP-1 RA: reduces albuminuria (semaglutide SQ — first GLP-1 RA with proven CKD endpoint)
Finerenone (non-steroidal MRA): ↓ CKD progression + CV events in T2DM+CKD+albuminuria
ACEi/ARB: reduce proteinuria; first-line
Metformin: stop if eGFR <30; use with caution 30–45

Non-Alcoholic / Metabolic Steatotic Liver Disease (MASLD)

GLP-1 RA (especially semaglutide SQ) — benefit in NASH/MASLD
Pioglitazone — proven hepatic steatosis benefit
Avoid alcohol; promote weight loss ≥7–10%

Source: ADA 2026, Sections 10 & 11

SLIDE 16 — SPECIAL POPULATIONS

Elderly Adults (Section 13)

Consideration	Recommendation
A1C target	7.5–8.0% (less stringent; up to 8.5% if frail/limited life expectancy)
Hypoglycemia risk	⚠️ High — prefer DPP-4i, low-dose GLP-1 RA
Sulfonylureas	Avoid glibenclamide — prolonged severe hypoglycemia
Insulin	Simplify regimen; use once-daily basal if needed
Cognitive impairment	Caregiver-focused education; avoid complex regimens
Fall risk	Avoid agents causing postural hypotension; exercise program for balance

Children & Adolescents (Section 14)

T2DM rising dramatically — screen after age 10 yrs or onset of puberty if BMI ≥85th percentile + ≥1 RF
First-line: metformin + lifestyle
Liraglutide and empagliflozin: FDA-approved for pediatric T2DM
A1C target: <7.0% (less stringent if hypoglycemia risk high)

Pregnancy & T2DM (Section 15)

Insulin is the preferred agent — most safety data
Metformin: used in GDM but crosses placenta — less preferred
GLP-1 RA, SGLT2i, DPP-4i: do NOT use in pregnancy
A1C target preconception: <6.0–6.5%; during pregnancy: <6.0% (if achievable without hypoglycemia)
Screen for GDM 24–28 weeks (one-step 75g OGTT or two-step approach)

People with T2DM + Mental Health Conditions

Depression: associated with worse glycemic outcomes — screen annually (PHQ-9)
Antipsychotic medications: ↑ T2DM risk — screen at baseline + 12–16 weeks + annually
Cognitive behavioral therapy + DSMES integration

Source: ADA 2026, Sections 13, 14, 15

SLIDE 17 — HYPOGLYCEMIA: RECOGNITION & MANAGEMENT

Definition (ADA 2026)

Level	Glucose Value	Clinical Significance
Level 1 (Alert)	< 70 mg/dL (<3.9 mmol/L)	Requires action; no severe symptoms
Level 2 (Clinically significant)	< 54 mg/dL (<3.0 mmol/L)	Requires urgent treatment
Level 3 (Severe)	No specific glucose threshold	Requires assistance from another person

Symptoms

Neurogenic (autonomic): Sweating, tremor, palpitations, hunger, anxiety
Neuroglycopenic: Confusion, slurred speech, weakness, visual changes, seizure, loss of consciousness

"Rule of 15" — Acute Treatment

✅ Confirm glucose <70 mg/dL
✅ Take 15g fast-acting carbohydrate (4 glucose tablets, 4 oz juice, 1 tbsp honey)
✅ Wait 15 minutes → recheck glucose
✅ Repeat if still <70 mg/dL
✅ Once resolved — eat a full meal or snack

Severe Hypoglycemia (Unable to Self-Treat)

IM or SQ glucagon (1 mg) — train caregivers
Nasal glucagon (3 mg) — convenient option
IV dextrose (D50W) if IV access available
Call 911 / transport to ED if no response

Prevention

Reduce or eliminate sulfonylurea/meglitinide when adding GLP-1 RA or SGLT2i (Rec 9.17)
Self-monitoring before driving, exercise, bedtime
CGM with low-glucose alerts

Source: ADA 2026, Section 6 (S132–S149)

SLIDE 18 — COMPLICATIONS OVERVIEW & PREVENTION

Microvascular Complications

Complication	Screening	Prevention / Treatment
Diabetic Retinopathy	Annual dilated eye exam	Optimize A1C, BP; anti-VEGF for neovascular disease; laser photocoagulation
Diabetic Nephropathy (DKD)	Annual UACR + eGFR	ACEi/ARB; SGLT2i; GLP-1 RA; finerenone; BP <130/80; restrict protein if advanced
Diabetic Peripheral Neuropathy	Annual foot exam (monofilament, vibration, ABI)	Optimize glycemia; TCAs, SNRIs, pregabalin/gabapentin, duloxetine for pain
Autonomic Neuropathy	Clinical assessment	Glycemic control; gastroparesis → dietary modification + prokinetics

Macrovascular Complications

Complication	Primary Prevention	Secondary Prevention
ASCVD (CAD, stroke, PAD)	Statin + ACEi/ARB + aspirin (in established CVD)	GLP-1 RA / SGLT2i with proven CV benefit
Heart Failure	SGLT2i in high-risk patients	SGLT2i (dapa/empa) proven to ↓ HF hospitalization
Stroke	BP control + statin + antiplatelet (established CVD)	Lifestyle modification + optimal glycemia

Complication Monitoring Schedule

Retinopathy: Annual (q2yr if stable, no retinopathy)
Nephropathy (UACR + eGFR): Annual
Neuropathy / foot exam: Annual (every visit if neuropathy present)
CVD risk factors (BP, lipids): Every visit (BP); annually (lipids)
Dental exam: Annually (bidirectional DM–periodontal disease)

Source: ADA 2026, Sections 10, 11, 12

SLIDE 19 — FOLLOW-UP & MONITORING SCHEDULE

Recommended Monitoring Frequency

Parameter	Frequency	Target / Notes
A1C	Every 3 months (if not at goal) / Every 6 months (stable)	<7.0% most adults
Blood pressure	Every visit	<130/80 mmHg
Weight / BMI	Every visit	≥5% loss targeted
Fasting lipid panel	Annually (or more if abnormal)	LDL-C <70 mg/dL (ASCVD)
Serum creatinine / eGFR	Annually (more if CKD)	Monitor with SGLT2i initiation
UACR	Annually	If elevated, repeat x2 to confirm
Foot exam	Annually minimum (every visit if neuropathy)	10g monofilament + vibration
Dilated eye exam	Annually (q2yr if stable, low-risk)	Retinopathy screening
Vitamin B12	Annually if on metformin ≥4 years	Supplement if deficient
Dental exam	Annually	DM–periodontal disease link
Depression / anxiety (PHQ-9)	Annually	Refer if positive
Smoking status	Every visit	Cessation counseling / pharmacotherapy

Immunizations (Section 4)

Influenza: annually
COVID-19: per current CDC/ACIP recommendations
Pneumococcal: PCV15 or PCV20 + PPSV23 (if <65 yrs); booster at ≥65
Hepatitis B: unvaccinated adults <60 yrs
Zoster (Shingrix): age ≥50 yrs

When to Refer

Endocrinology: A1C persistently >9% despite management; complex insulin regimens; suspected monogenic DM
Ophthalmology: any retinopathy; annual exam
Nephrology: eGFR <30, rapid decline, significant proteinuria
Cardiology: established CVD, HF, or pre-surgical clearance
Podiatry: peripheral arterial disease, foot ulcer, neuropathy
Dietitian/DSMES: at diagnosis, annually

Source: ADA 2026, Sections 4, 6, 10–12

SLIDE 20 — KEY TAKEAWAYS & SUMMARY

8 High-Yield Clinical Pearls from ADA 2026

1. 📋 DIAGNOSIS T2DM = A1C ≥6.5% OR FPG ≥126 mg/dL OR 2-h PG ≥200 mg/dL OR random PG ≥200 + symptoms. Confirm with 2 tests unless symptomatic hyperglycemic crisis.

2. 🔬 CLASSIFY CORRECTLY Use AABBCC tool when T1 vs T2 is unclear. Misclassification occurs in up to 40% of adult-onset T1DM. Consider islet autoantibody testing.

3. 💊 START EARLY Start pharmacotherapy at diagnosis — do not delay. Metformin remains first-line unless contraindicated.

4. ❤️ CARDIORENAL PROTECTION FIRST In patients with ASCVD, HF, or CKD → GLP-1 RA or SGLT2i regardless of A1C level. These agents reduce MACE, HF hospitalization, and CKD progression.

5. ⚖️ PREFER GLP-1 RA OVER INSULIN For most T2DM adults not at glycemic goal and without severe hyperglycemia → GLP-1 RA is preferred over insulin (ADA Rec 9.21). If insulin is used — combine with GLP-1 RA (Rec 9.22).

6. ⚠️ KNOW THE CONTRAINDICATIONS

Metformin: eGFR <30
SGLT2i: hold 3–4 days pre-surgery; T1DM
GLP-1 RA / tirzepatide: MTC / MEN-2; hold pre-anesthesia
TZDs: HF Class III/IV; bladder cancer
SU: elderly/CKD → ↑ hypoglycemia

7. 📏 INDIVIDUALIZE TARGETS A1C <7.0% for most adults. Less stringent (≤8.0–8.5%) for frail elderly, limited life expectancy, recurrent severe hypoglycemia, or burdensome-to-achieve goals.

8. 🔄 MONITOR COMPREHENSIVELY A1C (or CGM) + BP + lipids + eGFR + UACR + foot exam + eye exam — annually minimum. Address SDOH, DSMES, weight management, and mental health at every visit.

Source: American Diabetes Association Professional Practice Committee for Diabetes. Standards of Care in Diabetes — 2026. Diabetes Care 2026;49(Suppl. 1). DOI: https://doi.org/10.2337/dc26-SREV

All content sourced directly from ADA Standards of Care 2026 — for educational use only.

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T2DM ADA2026 20Slides
Presentation · PPTX

20 Slides — What's Inside

#	Slide Title
1	Title Slide
2	Overview — What Is T2DM? + 6 Pathophysiologic Defects
3	ADA 2026 Classification (all 4 types + AABBCC tool)
4	Diagnostic Criteria — Tables 2.1 & 2.2 (DM + Prediabetes)
5	Screening Flowchart — Who, When & How
6	Laboratory Evaluation + Glycemic Monitoring Options
7	Glycemic Targets — A1C, CGM (TIR/TBR/TAR), BGM
8	Non-Pharmacologic Treatment (MNT, Exercise, DSMES, Weight)
9	Pharmacologic Algorithm — 3-Step ADA 2026 Approach
10	Drug Classes Part 1 — Metformin, SGLT2i, GLP-1 RA, Tirzepatide
11	Drug Classes Part 2 — DPP-4i, Sulfonylureas, TZDs, Insulin
12	Full Drug Comparison Table (8 classes, 7 parameters)
13	Pharmacologic Contraindications (all 6 drug classes, red-coded)
14	Non-Pharmacologic Contraindications (exercise, diet, surgery, DSMES)
15	Hypoglycemia — Classification, Rule of 15, Glucagon
16	Complications — Micro & Macrovascular Screening + Treatment
17	Comorbidity Management (HTN, Dyslipidemia, CKD, MASLD)
18	Special Populations (Elderly, Obesity, HF, Children, Pregnancy)
19	Follow-Up Schedule + Monitoring Table + Vaccines + Referrals
20	Key Takeaways — 8 Clinical Pearls (dark title-style closing slide)

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🩺 TYPE 2 DIABETES MELLITUS

Comprehensive Clinical Presentation

ADA Standards of Care in Diabetes — 2026 Diabetes Care 2026;49(Suppl. 1)

SLIDE 1 — TITLE

Type 2 Diabetes Mellitus

ADA Standards of Care 2026

Presenter: [Your Name] Institution / Course: [Course Name] Date: June 2026

"Diabetes is a complex, chronic condition requiring continuous care with comprehensive risk-reduction strategies beyond glycemic management." — ADA Standards of Care, 2026

Source: ADA Professional Practice Committee for Diabetes. Standards of Care in Diabetes — 2026. Diabetes Care 2026;49(Suppl. 1). https://doi.org/10.2337/dc26-SREV

SLIDE 2 — OVERVIEW: What Is Type 2 Diabetes?

Definition (ADA 2026, Section 2)

Pathophysiology: Non-autoimmune progressive loss of adequate β-cell insulin secretion, frequently on the background of insulin resistance.

At a Glance

Feature	T2DM
% of all diabetes	90–95%
Primary defect	Insulin resistance + progressive β-cell dysfunction
Immune-mediated?	❌ No
DKA risk	Rare — can occur with stress, illness, or SGLT2i use
HHS risk	✅ Yes — more typical of T2DM
Onset	Often insidious; hyperglycemia gradual; silent for years

Global Burden

537 million adults living with diabetes worldwide (IDF 2021)
Prevalence rising sharply in children and adolescents
Often undiagnosed for years → macro- and microvascular complications accumulate silently
Duration of glycemic burden is the strongest predictor of adverse outcomes

6 Key Pathophysiologic Defects

Insulin Resistance — skeletal muscle, liver, adipose tissue fail to respond to insulin
Progressive β-cell Dysfunction — genetic + epigenetic + metabolic stress → β-cell exhaustion
Incretin Defect — ↓ GLP-1/GIP effect → impaired postprandial insulin secretion
Glucotoxicity / Lipotoxicity — chronic hyperglycemia + FFA worsen β-cell function (vicious cycle)
↑ Hepatic Glucose Output — inappropriate gluconeogenesis/glycogenolysis despite hyperglycemia
Abnormal α-cell Function — inappropriately elevated glucagon drives hepatic glucose output

ADA 2026, Section 2 (S27–S49)

SLIDE 3 — CLASSIFICATION OF DIABETES (ADA 2026)

ADA 2026 — Four Main Categories (Rec 2.5)

Category	Key Features
Type 1 DM	Autoimmune β-cell destruction → absolute insulin deficiency. Includes LADA. 5–10% of all DM.
⭐ Type 2 DM	Non-autoimmune progressive β-cell failure + insulin resistance. 90–95% of all DM. This presentation.
Gestational DM (GDM)	Diagnosed in 2nd/3rd trimester. Not clearly overt DM prior to gestation. Screen all at 24–28 wks.
Other Specific Types	Monogenic DM (MODY, neonatal DM), pancreatic disease (Type 3c), drug-induced, post-transplant (PTDM)

Differentiating T1 vs T2 — the AABBCC Tool

When diabetes type is unclear at presentation, use:

Letter	Stands For	Favors T1DM
A	Age	< 35 years
A	Autoimmunity	Personal/family Hx of autoimmune disease
B	Body habitus	BMI < 25 kg/m²
B	Background	Family Hx of T1DM
C	Control	Unable to achieve glycemic goals on non-insulin agents
C	Comorbidities	Immune checkpoint inhibitor therapy → acute autoimmune DM

⚠️ Important: Misclassification occurs in up to 40% of adults with new-onset T1DM. T2DM with DKA is possible — especially in Black and Hispanic/Latino adults (ketosis-prone diabetes).

ADA 2026, Section 2 (S30–S36); Holt et al., Diabetes Care 2021

SLIDE 4 — DIAGNOSTIC CRITERIA (ADA 2026)

Criteria for Diagnosis of Diabetes — Nonpregnant Individuals (Table 2.1)

Test	Diabetes Threshold	Notes
A1C	≥ 6.5% (≥48 mmol/mol)	NGSP-certified, DCCT-standardized lab required
Fasting Plasma Glucose (FPG)	≥ 126 mg/dL (≥7.0 mmol/L)	Fasting = no caloric intake ≥8 hours
2-h PG during 75g OGTT	≥ 200 mg/dL (≥11.1 mmol/L)	150g carbs/day × 3 days before test (WHO protocol)
Random Plasma Glucose + Symptoms	≥ 200 mg/dL (≥11.1 mmol/L)	Classic Sx: polyuria, polydipsia, unexplained weight loss OR hyperglycemic crisis

⚠️ Confirmation Rule: In the absence of unequivocal hyperglycemia → 2 abnormal results from the same or different tests are required (same visit or 2 separate time points).

Prediabetes Criteria (Table 2.2)

Test	Prediabetes Range	Category
A1C	5.7–6.4% (39–47 mmol/mol)	—
FPG	100–125 mg/dL (5.6–6.9 mmol/L)	Impaired Fasting Glucose (IFG)
2-h PG (75g OGTT)	140–199 mg/dL (7.8–11.0 mmol/L)	Impaired Glucose Tolerance (IGT)

When NOT to Use A1C — Use Plasma Glucose Instead

Hemoglobin variants (sickle cell trait)
Altered RBC turnover: anemia, hemolysis, G6PD deficiency
HIV, cirrhosis, CKD, dialysis
Pregnancy (iron deficiency → falsely ↑ A1C)
Recent blood transfusion or erythropoietin use

ADA 2026, Section 2 (S27–S29); Recs 2.1–2.4

SLIDE 5 — SCREENING FLOWCHART

Who to Screen (Table 2.5) — Asymptomatic Adults

Screen at ANY age if overweight/obese (BMI ≥25, or ≥23 in Asian individuals) + ≥1 of:

First-degree relative with diabetes
High-risk race/ethnicity (African American, Latino, Native American, Asian American)
History of cardiovascular disease
HTN ≥130/80 mmHg (or on antihypertensive therapy)
HDL <35 mg/dL and/or triglycerides >250 mg/dL
Polycystic ovary syndrome (PCOS)
Physical inactivity
Acanthosis nigricans, MASLD, severe obesity

Screen ALL adults regardless of weight starting at age 35

Special Groups

Prior GDM → every 1–3 years
Prediabetes → annually
Glucocorticoids, statins, thiazides → screen at initiation
Antipsychotics → baseline + 12–16 weeks + annually
HIV → FPG before ARV, at switch, 3–6 months after

Screening Flowchart

        ASYMPTOMATIC ADULT
               │
               ▼
    ┌──────────────────────┐
    │  STEP 1              │
    │  Risk Assessment     │
    │  Age ≥35?  ──────────┼──► SCREEN
    │  Overweight + RF? ───┼──► SCREEN
    │  Prediabetes/GDM? ───┼──► SCREEN ANNUALLY
    │  No risk, age <35 ───┼──► ROUTINE CARE
    └──────────┬───────────┘
               │
               ▼
    ┌──────────────────────┐
    │  STEP 2              │
    │  Choose Test         │
    │  FPG or A1C          │
    │  OR 75g 2-h OGTT     │
    │  (most sensitive)    │
    └──────┬───────┬───────┘
           │       │
     ┌─────▼─┐  ┌──▼──────────┐
     │NORMAL │  │PREDIABETES  │
     │Repeat │  │Lifestyle Rx │
     │3 yrs  │  │± Metformin  │
     └───────┘  │Retest yearly│
                └──────┬──────┘
                       │
                       ▼
           ┌───────────────────────┐
           │  DIABETES (T2DM)      │
           │  A1C ≥6.5%           │
           │  FPG ≥126 mg/dL      │
           │  2-h PG ≥200         │
           │  Random ≥200 + Sx    │
           │  ⚠ Confirm with 2    │
           │  tests (no Sx/crisis)│
           └───────────┬───────────┘
                       │
                       ▼
           ┌───────────────────────┐
           │  CLASSIFY TYPE        │
           │  Use AABBCC tool      │
           │  → Start Treatment    │
           └───────────────────────┘

ADA 2026, Section 2; Recs 2.11–2.18

SLIDE 6 — LABORATORY EVALUATION

Initial Workup at T2DM Diagnosis

Lab Test	Rationale
A1C (NGSP-certified)	Confirms diagnosis + baseline glycemic control
Fasting lipid panel	LDL-C, HDL-C, TG, Total Cholesterol — CV risk baseline
Serum creatinine + eGFR	Baseline kidney function; CKD detection
Urine albumin-to-creatinine ratio (UACR)	Early nephropathy detection (spot urine)
Liver function tests (ALT/AST)	MASLD screening; pre-metformin baseline
TSH	Thyroid disease common in DM; impacts glycemia
Vitamin B12	Baseline before starting metformin
Blood pressure	Every visit; goal <130/80 mmHg
BMI + weight	Every visit; weight management planning
Foot exam	10g monofilament + vibration sense — baseline neuropathy
Dilated fundus exam	Baseline retinopathy screening

Glycemic Monitoring Options

Method	What It Measures	When to Prefer
A1C	2–3 month average glucose	Standard monitoring at every visit
CGM — TIR	% time 70–180 mg/dL	On insulin; frequent hypoglycemia
CGM — TBR	% time < 70 mg/dL	Key safety metric for all insulin users
CGM — TAR	% time > 180 mg/dL	Assess postprandial control
GMI	Estimated A1C from CGM data	When A1C and CGM are discordant
BGM (fingerstick)	Point-in-time glucose	Adjunct; cost-effective alternative
Fructosamine / Glycated albumin	~2–3 week average	When A1C unreliable (hemoglobinopathy, hemolysis, CKD, pregnancy)

Monitoring Frequency (Rec 6.2): Stable at goal → A1C every 6 months. Not at goal or medication change → every 3 months.

ADA 2026, Sections 4 & 6 (S61–S149)

SLIDE 7 — GLYCEMIC TARGETS (ADA 2026, Section 6)

A1C Targets by Population

Population	A1C Target
Most non-pregnant adults	< 7.0% (<53 mmol/mol)
Young/newly diagnosed, long life expectancy, no hypoglycemia risk	< 6.5% if safely achievable
Frail elderly, limited life expectancy, high hypoglycemia risk	< 8.0–8.5%
Pregnancy — preconception	< 6.0–6.5%
Pregnancy — during gestation	< 6.0% (if achievable without significant hypoglycemia)

CGM-Based Glycemic Targets

CGM Metric	Standard Target	Elderly / High-Risk
TIR (70–180 mg/dL)	> 70% of time	> 50%
TBR (< 70 mg/dL)	< 4%	< 4%
Critical Low (< 54 mg/dL)	< 1%	< 1%
TAR (> 180 mg/dL)	< 25%	—

BGM (Fingerstick) Targets

Pre-meal: 80–130 mg/dL
Peak postprandial (1–2 hrs after meal): < 180 mg/dL

Key Individualization Principles

Tighter control: young patients, newly diagnosed, no comorbidities, high motivation
Relaxed goals: frail elderly, dementia, recurrent severe hypoglycemia, limited life expectancy, high treatment burden
Shared decision-making — involve the patient in every goal-setting conversation
Re-assess and adjust goals at every clinical encounter
De-intensify therapy when goals are too stringent and burdensome
A1C and CGM metrics are complementary — use both when available (Rec 6.1)

ADA 2026, Section 6 (S132–S149); Recs 6.1–6.6

SLIDE 8 — NON-PHARMACOLOGIC TREATMENT

1. Medical Nutrition Therapy (MNT)

Goal: 5–10% weight reduction → meaningful glycemic improvement; ≥15% → possible T2DM remission
No single optimal eating pattern — all supported by evidence:
- Mediterranean diet ✅
- DASH diet ✅
- Low-carbohydrate diet ✅
- Plant-based diet ✅
Reduce: refined carbohydrates, added sugars, ultra-processed foods, sodium (<2,300 mg/day)
Increase: dietary fiber (vegetables, legumes, whole grains)
Limit alcohol — hypoglycemia risk with insulin/sulfonylurea
Refer to registered dietitian for individualized MNT counseling

2. Physical Activity (Section 5)

Aerobic: ≥150 min/week moderate-intensity (brisk walking, cycling, swimming)
Resistance training: ≥2 days/week — improves insulin sensitivity independently
Break prolonged sitting every 30 minutes
Benefits: A1C ↓ ~0.5–1.0%, weight loss, BP reduction, lipid improvement
⚠️ Pre-exercise glucose check if on insulin or sulfonylurea
Carry fast-acting carbohydrate if on SU or insulin

3. DSMES — Diabetes Self-Management Education & Support

Recommended at: diagnosis, annually, when complicating factors arise, care transitions
ADA-recognized or CDC-recognized DPP (Diabetes Prevention Program) programs
Covers: self-monitoring, medication management, foot care, sick-day rules, hypoglycemia rescue
Use teach-back method; assess health literacy
Address social determinants of health (SDOH): food security, housing, transportation, financial barriers

4. Weight Management (Section 8)

5–10% weight loss → clinically meaningful glycemic benefit
≥15% weight loss → T2DM remission possible (DiRECT, DIADEM-I trials)
Intensive lifestyle intervention (ILI) + very low calorie diet (VLCD) supported
Metabolic/bariatric surgery: BMI ≥40 (or ≥35 with comorbidities) — can achieve remission
GLP-1 RA and dual GIP/GLP-1 RA: first-line pharmacologic weight management adjuncts
Re-evaluate glucose-lowering regimen after significant weight loss (de-intensify)

5. Tobacco & Behavioral Health

Smoking cessation at every visit — worsens CV risk and glycemia
Alcohol: moderate use only; never on empty stomach (hypoglycemia risk with SU/insulin)
Depression screening (PHQ-9): annually — depression worsens glycemic outcomes

ADA 2026, Sections 5 & 8

SLIDE 9 — PHARMACOLOGIC TREATMENT ALGORITHM

⚡ Key principle: Start pharmacotherapy AT DIAGNOSIS — do not delay. GLP-1–based therapy is preferred over insulin for most T2DM patients not in hyperglycemic crisis. (Recs 9.15, 9.21)

🟦 STEP 1 — All T2DM at Diagnosis

✅ Metformin (unless contraindicated)
✅ Lifestyle modification (MNT + physical activity)
✅ DSMES referral
✅ Address social determinants of health

🟩 STEP 2 — Comorbidity-Driven Add-On Therapy (A1C not at goal)

Clinical Priority	Preferred Agent	Evidence
Established ASCVD / High CV risk	GLP-1 RA (sema, lira, dula) OR SGLT2i (empa, cana, dapa)	SUSTAIN-6, LEADER, REWIND, EMPA-REG, CANVAS
Heart Failure (HFrEF or HFpEF)	SGLT2 inhibitor (empa, cana, dapa)	EMPEROR, DAPA-HF, CANVAS
Chronic Kidney Disease	SGLT2i + GLP-1 RA; add finerenone if albuminuria	CREDENCE, DAPA-CKD, FLOW
Need weight loss	GLP-1 RA or dual GIP/GLP-1 RA (tirzepatide)	SURMOUNT-2, SURPASS-4
Minimize hypoglycemia	DPP-4i, GLP-1 RA, SGLT2i (all low hypo risk)	—
Cost concern	Sulfonylurea, TZD, NPH insulin (all generic/low-cost)	—

🟥 STEP 3 — Severe Hyperglycemia

(A1C >10% OR glucose ≥300 mg/dL OR symptomatic hyperglycemia)

Initiate insulin (basal insulin preferred as initial approach)
GLP-1 RA + insulin combination preferred over insulin alone — greater efficacy, less hypoglycemia, weight benefit (Rec 9.22)
↓ sulfonylurea/meglitinide dose when adding insulin — ↑ hypoglycemia risk (Rec 9.17)
Reassess and de-intensify once glycemia controlled
Avoid combining DPP-4i + GLP-1 RA — no additive benefit (Rec 9.18)

ADA 2026, Section 9 (S183–S215); Recs 9.15–9.23

SLIDE 10 — DRUG CLASSES: Metformin, SGLT2i, GLP-1 RA

Metformin — First-Line Foundation

Feature	Detail
MOA	↓ hepatic glucose output (AMPK activation) + ↑ peripheral insulin sensitivity
Efficacy	High — A1C ↓ ~1.0–1.5%
Hypoglycemia	None
Weight	Neutral (modest loss possible)
Key AEs	GI: nausea, diarrhea, bloating — mitigate with slow titration, ER formulation, take with food; Vitamin B12 deficiency (monitor if on ≥4 yrs)
Contraindications	eGFR <30; active hepatic disease; alcohol abuse; hold 48h before IV iodinated contrast

SGLT2 Inhibitors (empagliflozin, canagliflozin, dapagliflozin, ertugliflozin)

Feature	Detail
MOA	Block SGLT2 in proximal tubule → glucosuria (excrete ~150g glucose/day)
Efficacy	Intermediate–High — A1C ↓ 0.5–1.0%
Hypoglycemia	None
Weight	Moderate loss (~2–3 kg)
CV Benefits	↓ MACE (empa, cana); ↓ HF hospitalization (empa, cana, dapa, ertu); ↓ CKD progression (empa, cana, dapa)
Key AEs	Genital mycotic infections, UTI/urosepsis, DKA (rare in T2DM), Fournier's gangrene (rare), volume depletion, ↑ LDL (modest)
Contraindications	T1DM (↑ DKA risk); hold 3–4 days pre-surgery; eGFR <20 for glucose lowering

GLP-1 Receptor Agonists (semaglutide, liraglutide, dulaglutide, exenatide)

Feature	Detail
MOA	GLP-1 mimetic → glucose-dependent insulin ↑, glucagon ↓, ↓ gastric emptying, ↑ satiety
Efficacy	High–Very High — A1C ↓ 1.0–1.8%; semaglutide = highest efficacy
Hypoglycemia	None
Weight	5–10% body weight loss
CV Benefits	↓ MACE (sema SQ/oral, lira, dula); ↓ albuminuria; sema SQ → ↓ CKD hard endpoints (FLOW trial)
Key AEs	Nausea/vomiting, pancreatitis (rare), biliary disease, NAION (rare); hold before general anesthesia (aspiration risk)
Contraindications	Personal/family Hx medullary thyroid carcinoma (MTC) or MEN-2; hold before procedures requiring anesthesia/deep sedation

Dual GIP/GLP-1 RA — Tirzepatide (Mounjaro®)

Feature	Detail
MOA	Dual agonist — activates both GIP and GLP-1 receptors simultaneously
Efficacy	Very High — A1C ↓ ~2.0–2.4% (SURPASS trials) — highest of any non-insulin agent
Weight	Very High loss — up to ~22% body weight (SURMOUNT trials)
CV	Tirzepatide → ↓ HF outcomes (SUMMIT trial); MACE outcome trial ongoing
AEs	Same GI profile as GLP-1 RA; same thyroid C-cell / pancreatitis precautions

ADA 2026, Section 9, Table 9.2

SLIDE 11 — DRUG CLASSES: DPP-4i, Sulfonylureas, TZDs, Insulin

DPP-4 Inhibitors (sitagliptin, saxagliptin, alogliptin, linagliptin)

Feature	Detail
MOA	Inhibit DPP-4 → prevent GLP-1/GIP degradation → ↑ incretin effect
Efficacy	Moderate — A1C ↓ ~0.5–0.8%
Hypoglycemia	None
Weight	Neutral
Key AEs	Pancreatitis (rare); saxagliptin & alogliptin → ↑ HF hospitalization risk
Dosing	Dose-adjust for CKD — ALL agents except linagliptin (hepatically cleared)

Sulfonylureas (glipizide, glimepiride, glyburide/glibenclamide)

Feature	Detail
MOA	Stimulate β-cell insulin release via ATP-sensitive K⁺ channel closure (glucose-independent)
Efficacy	High — A1C ↓ ~1.0–1.5%
Hypoglycemia	⚠️ HIGH RISK — most common serious AE
Weight	Gain (~2 kg)
Preferred agent	Glipizide (shortest acting) — safer in elderly/CKD
Key AEs	Hypoglycemia (especially glibenclamide in elderly/CKD), weight gain
Contraindications	Pregnancy (use insulin); severe renal/hepatic impairment; frail elderly

TZDs — Thiazolidinediones (pioglitazone)

Feature	Detail
MOA	PPARγ agonist → ↑ adipose insulin sensitivity; ↑ hepatic and muscle glucose uptake
Efficacy	High — A1C ↓ ~0.8–1.4%; durable effect
Hypoglycemia	None
Weight	Gain
CV	Pioglitazone — CV benefit (PROactive trial); hepatic benefit in MASLD
Key AEs	Fluid retention/edema, weight gain, ↑ fracture risk (especially women), bladder cancer risk (pioglitazone)
Contraindications	HF NYHA Class III/IV (absolute); bladder cancer Hx; osteoporosis/high fracture risk; pregnancy

Insulin Therapy

Feature	Detail
Efficacy	Highest — no ceiling effect
Hypoglycemia	⚠️ HIGH RISK
Weight	Gain
Types	Rapid (lispro, aspart, glulisine), Ultra-rapid (URAA), Short (regular), Intermediate (NPH), Long-acting (glargine U-100/U-300, detemir, degludec)
First choice in T2DM	Basal insulin (once daily) — preferred initial insulin
Key principles	GLP-1 RA + insulin preferred over insulin alone (Rec 9.22); ↓ SU when adding insulin (Rec 9.17); adjust dose with exercise, illness, fasting

⚠️ Combination to Avoid

DPP-4i + GLP-1 RA: No additive benefit — do NOT combine (Rec 9.18)
TZD + Insulin: ↑ fluid retention → ↑ HF risk
Glibenclamide in elderly or CKD: prolonged severe hypoglycemia

ADA 2026, Section 9, Table 9.2

SLIDE 12 — DRUG COMPARISON TABLE (ADA 2026, Table 9.2)

Agent	Efficacy	Hypo?	Weight	CV Effect	Kidney Effect	Key AE / CI
Metformin	High	No	Neutral/↓	Potential benefit	Neutral	GI; B12↓; CI: eGFR <30
SGLT2i	Int–High	No	Loss	↓ MACE/HF ✅	↓ CKD progression ✅	Genital infxn; DKA (rare); hold pre-surg
GLP-1 RA	High–V.High	No	Loss (mod–high)	↓ MACE ✅	↓ Albuminuria ✅	Nausea; pancreatitis; CI: MTC/MEN-2
Dual GIP/GLP-1 (tirzepatide)	Very High	No	Very High Loss	↓ HF (SUMMIT)	Potential benefit	GI; same as GLP-1 RA precautions
DPP-4 Inhibitors	Moderate	No	Neutral	Neutral	Neutral	Pancreatitis (rare); sax/alo → ↑ HHF
Sulfonylureas	High	⚠️ YES	Gain	Neutral	Neutral	⚠️ Hypoglycemia; wt gain; ⚠️ CKD/elderly
TZDs (pioglitazone)	High	No	Gain	Benefit (pio)	Neutral	Edema; fractures; bladder CA; CI: HF III/IV
Insulin	Highest	⚠️ YES	Gain	Neutral	Neutral	⚠️ Hypoglycemia; wt gain; injection site

⚠️ Agents marked YES for hypoglycemia require patient education, dose adjustment planning, and glucagon prescription. CI = contraindicated | HHF = hospitalization for heart failure | MTC = medullary thyroid carcinoma ADA 2026, Section 9, Table 9.2

SLIDE 13 — PHARMACOLOGIC CONTRAINDICATIONS

⛔ Metformin

Absolute: eGFR <30 mL/min/1.73m²
eGFR 30–45: use with caution; monitor kidney function closely
Active liver disease / alcohol abuse (↑ lactic acidosis risk)
Hold 48 hours before iodinated contrast studies
Hold perioperatively for major surgical procedures

⛔ SGLT2 Inhibitors

Absolute: T1DM — significantly ↑ DKA risk
Hold 3–4 days before surgery, prolonged fasting, or critical illness
Glucose-lowering effect ↓ at eGFR <45 (but continue for CV/renal benefit if eGFR >20)
Recurrent UTI or predisposition to genital infections (relative CI)
Pregnancy

⛔ GLP-1 RA / Tirzepatide

Absolute: Personal OR family history of medullary thyroid carcinoma (MTC)
Absolute: Multiple Endocrine Neoplasia type 2 (MEN-2)
High risk of pancreatitis (gallstones, severe hypertriglyceridemia)
Severe GI motility disorders (gastroparesis)
Hold before procedures requiring general anesthesia/deep sedation (aspiration risk)
Pregnancy

⛔ DPP-4 Inhibitors

History of pancreatitis — relative CI; use with caution
Saxagliptin & alogliptin: ↑ HF hospitalization risk — avoid in established HF
Dose adjustment required for CKD (ALL agents except linagliptin)

⛔ Sulfonylureas

Pregnancy — use insulin instead (sulfonylureas cross the placenta)
Severe CKD — especially avoid glibenclamide (prolonged severe hypoglycemia)
Frail elderly — ↑ fall risk and hypoglycemia risk; prefer shorter-acting glipizide
Significant hepatic impairment

⛔ TZDs (Pioglitazone)

Heart Failure NYHA Class III or IV — absolute contraindication (fluid retention worsens HF)
Active bladder cancer or history of bladder cancer (pioglitazone)
Osteoporosis / high fracture risk — TZDs ↑ fracture risk especially in women
Active/significant liver disease
Pregnancy

ADA 2026, Section 9, Table 9.2 — Always verify current prescribing information

SLIDE 14 — NON-PHARMACOLOGIC CONTRAINDICATIONS & PRECAUTIONS

⚠️ Exercise & Physical Activity — Defer or Modify When:

Condition	Precaution
BG >300 mg/dL (or >250 mg/dL with ketones)	Defer vigorous exercise — stabilize glycemia first
Recent DKA or HHS	Full recovery and medical clearance required before resuming
Severe proliferative diabetic retinopathy	Avoid high-intensity or jarring exercise (vitreous hemorrhage risk)
Peripheral neuropathy / active foot ulcer	Non-weight-bearing exercise preferred (swimming, cycling, water aerobics)
Autonomic neuropathy	Orthostatic hypotension risk; cardiac screening before vigorous program
On insulin or sulfonylurea	Carry fast-acting carbohydrate; check BG pre/during/post exercise
Recent MI, unstable angina, decompensated HF	Cardiology clearance required before vigorous activity

⚠️ Dietary & Nutritional Precautions

Intervention	Caution
Very low carbohydrate diet (<50g/day)	↓ insulin/SU dose to prevent hypoglycemia; monitor closely
Extended fasting / time-restricted eating	Coordinate with insulin dosing; not recommended without monitoring plan
High-protein diet in CKD	May worsen kidney function; consult renal dietitian
Alcohol use	Hypoglycemia with SU/insulin; never drink on empty stomach; moderate use only
Post-bariatric surgery	Risk: dumping syndrome, hypoglycemia, B12/iron/Ca²⁺/vitamin D deficiency

⚠️ Metabolic/Bariatric Surgery — Contraindications

Active substance use disorder
Unstable psychiatric conditions (uncontrolled severe depression, psychosis, active suicidality)
Inability to comply with post-op nutritional supplements and lifelong follow-up
Active malignancy (relative CI)
Pregnancy (relative CI)
Severe cardiac/pulmonary disease (anesthesia risk — relative)

⚠️ DSMES — Adaptations Required (Not Absolute CIs, But Mandatory Modifications)

Severe cognitive impairment: caregiver-focused education; simplified regimens; avoid complex carb counting
Active mental health crisis: stabilize psychiatric condition first; then DSMES
Low health literacy: visual aids, simple language, teach-back method, written action plans
Food insecurity / SDOH barriers: refer to social work; community meal programs; personalize realistic goals

ADA 2026, Sections 5 & 8

SLIDE 15 — HYPOGLYCEMIA: Recognition & Management

ADA 2026 Classification

Level	Glucose Threshold	Clinical Significance
Level 1 — Alert Value	< 70 mg/dL (<3.9 mmol/L)	Requires action; no severe symptoms necessarily present
Level 2 — Clinically Significant	< 54 mg/dL (<3.0 mmol/L)	Requires urgent treatment; serious hypoglycemia
Level 3 — Severe	No specific BG threshold	Altered consciousness; requires assistance from another person

Symptoms

Neurogenic (autonomic): sweating, tremor, palpitations, hunger, anxiety, pallor
Neuroglycopenic: confusion, slurred speech, weakness, visual changes, seizure, loss of consciousness

Risk Factors in T2DM

On sulfonylurea or insulin (especially basal + bolus)
Skipping or delaying meals
Increased exercise without dose adjustment
Alcohol consumption on empty stomach
Renal impairment (↓ drug clearance)
Older age / cognitive impairment
Tight glycemic control (A1C <6.5% in high-risk patients)

"Rule of 15" — Acute Management (Level 1/2)

✅ Confirm BG < 70 mg/dL
✅ Take 15g fast-acting carbohydrate:
- 4 glucose tablets
- 4 oz (120 mL) fruit juice or regular soda
- 1 tablespoon honey or table sugar
✅ Wait 15 minutes → recheck BG
✅ Repeat if still < 70 mg/dL
✅ Once resolved → eat a full meal or snack to prevent recurrence

Severe Hypoglycemia (Level 3) — Treatment

IM or SQ Glucagon 1 mg — train ALL caregivers
Nasal glucagon 3 mg — convenient; no reconstitution needed
IV Dextrose (D50W) — if IV access available
Call 911 if no response to glucagon within 15 minutes

Prevention

↓ or eliminate SU/meglitinide when adding GLP-1 RA or SGLT2i (Rec 9.17)
CGM with low-glucose alerts
Educate on sick-day rules and exercise adjustments
Self-monitor before driving, exercise, and bedtime
Prescribe glucagon kit for all patients on insulin or SU

ADA 2026, Section 6 (S132–S149)

SLIDE 16 — COMPLICATIONS: Screening, Prevention & Treatment

Microvascular Complications

Complication	Screening Method	Frequency	Prevention / Treatment
Diabetic Retinopathy	Dilated fundus exam	Annually (q2yr if stable, no retinopathy)	Optimize A1C & BP; anti-VEGF for neovascular disease; laser photocoagulation
Diabetic Kidney Disease	UACR + eGFR	Annually	ACEi/ARB; SGLT2i; GLP-1 RA; finerenone; BP <130/80; protein restriction if advanced
Peripheral Neuropathy	10g monofilament + vibration + ABI	Annually	Optimize glycemia; TCAs, SNRIs, gabapentin/pregabalin, duloxetine for neuropathic pain
Autonomic Neuropathy	Clinical assessment + HR variability	Annually	Glycemic control; gastroparesis: dietary modification + prokinetics (metoclopramide, domperidone)

Macrovascular Complications

Complication	Screening	Prevention	Preferred Treatment Agents
ASCVD (CAD, Stroke, PAD)	10-yr CV risk; symptoms; ECG	Statin + ACEi/ARB; aspirin (established CVD only)	GLP-1 RA (sema, lira, dula) or SGLT2i with proven MACE benefit
Heart Failure	Echo; BNP if symptomatic	SGLT2i in high-risk patients	SGLT2i (dapa, empa) → ↓ HF hospitalization + CV death; avoid TZDs and sax/alo
Peripheral Artery Disease	ABI if claudication or foot ulcer	Smoking cessation; BP + lipid control	Semaglutide SQ — ↓ MACE including PAD events

Complication Monitoring Summary

Retinopathy: Annual dilated eye exam (ophthalmologist or optometrist)
Nephropathy: Annual UACR + eGFR; if elevated UACR, repeat ×2 to confirm
Neuropathy: Annual foot exam; every visit if neuropathy present
CV risk: BP every visit; lipid panel annually

ADA 2026, Sections 10, 11, 12

SLIDE 17 — COMORBIDITY MANAGEMENT

Hypertension — BP Target <130/80 mmHg (Section 10)

First-line: ACEi or ARB — especially with proteinuria, CKD, or HF
Second-line: CCB or thiazide diuretic
⚠️ Avoid combining ACEi + ARB simultaneously (↑ AKI risk)
Reassess BP at every clinical encounter
Resistant HTN: add aldosterone antagonist (spironolactone); refer nephrology

Dyslipidemia (Section 10)

LDL-C target:
- Established ASCVD: < 70 mg/dL
- High risk (no ASCVD): < 100 mg/dL
High-intensity statin first-line (atorvastatin 40–80 mg; rosuvastatin 20–40 mg)
If LDL not at goal on max statin: add ezetimibe first → then PCSK9 inhibitor
TG >500 mg/dL: fibrates or omega-3 to prevent pancreatitis
Non-HDL-C target: <100 mg/dL (ASCVD); <130 mg/dL (no ASCVD)

Antiplatelet Therapy

Aspirin 75–100 mg/day: established ASCVD (secondary prevention) ✅
NOT routinely recommended for primary prevention in T2DM (↑ bleeding risk outweighs benefit)

CKD Management (Section 11)

ACEi or ARB: first-line for CKD + albuminuria — reduce proteinuria + CKD progression
SGLT2i (eGFR >20): slow CKD progression — continue until dialysis or transplant
GLP-1 RA: reduces albuminuria; semaglutide SQ — first to show ↓ CKD hard endpoints (FLOW trial)
Finerenone (non-steroidal MRA): ↓ CKD progression + CV events in T2DM + CKD + albuminuria
Metformin: stop if eGFR <30; reduce dose if eGFR 30–45

MASLD / Liver Disease

Screen with LFTs; elastography or biopsy if persistent elevation
GLP-1 RA (especially semaglutide): benefit in NASH/MASLD — ↓ hepatic fat and inflammation
Pioglitazone: proven hepatic steatosis and inflammation benefit
Weight loss ≥7–10%: most effective lifestyle intervention
Avoid hepatotoxic agents; monitor LFTs on thiazolidinediones

ADA 2026, Sections 10 & 11

SLIDE 18 — SPECIAL POPULATIONS

Elderly & Frail Adults (Section 13)

Consideration	Recommendation
A1C target	7.5–8.0% (up to 8.5% if frail, dementia, limited life expectancy)
Preferred agents	DPP-4i, low-dose GLP-1 RA (low hypoglycemia risk)
Agents to AVOID	Glibenclamide — prolonged severe hypoglycemia
Insulin	Simplify to once-daily basal; avoid complex regimens
Cognitive function	Screen annually; caregiver-focused education
Falls	Avoid agents causing orthostatic hypotension

Children & Adolescents (Section 14)

Screen after age 10 or onset of puberty if BMI ≥85th percentile + ≥1 risk factor
First-line: metformin + lifestyle modification
FDA-approved for pediatric T2DM: liraglutide, empagliflozin, dapagliflozin
A1C target: <7.0% (less stringent if hypoglycemia risk is high)
Youth-onset T2DM is more aggressive — earlier CV complications than in adults

Obesity (Section 8)

First-line pharmacologic weight loss: GLP-1 RA or tirzepatide
Tirzepatide: up to ~22% body weight loss — highest of any approved agent
Metabolic surgery: BMI ≥40 or ≥35 with comorbidities — can achieve T2DM remission
Re-evaluate glucose-lowering regimen after significant weight loss (de-intensify)

Heart Failure (Section 10)

SGLT2i (dapagliflozin, empagliflozin): reduce HF hospitalization + CV death in HFrEF and HFpEF
AVOID in HF: saxagliptin, alogliptin (↑ HF hospitalization)
AVOID: TZDs in NYHA Class III/IV — absolute contraindication
Tirzepatide: potential benefit in HFpEF (SUMMIT trial)

Pregnancy (Section 15)

Insulin: preferred agent — most safety data
Metformin: crosses placenta — less preferred by ADA for T2DM in pregnancy
GLP-1 RA, SGLT2i, DPP-4i: do NOT use in pregnancy (insufficient safety data)
A1C preconception: <6.0–6.5%
GDM screen: 24–28 weeks with 75g OGTT (one-step) or two-step approach

Mental Health

Depression: associated with worse glycemic outcomes — screen annually (PHQ-9)
Antipsychotics: ↑ T2DM risk — screen at baseline + 12–16 weeks + annually
Diabetes distress is distinct from clinical depression — address at every visit

ADA 2026, Sections 13, 14, 15

SLIDE 19 — FOLLOW-UP SCHEDULE & MONITORING PLAN

Recommended Monitoring Frequency

Parameter	Frequency	Target / Goal	Action if Abnormal
A1C	q3 months (not at goal) / q6 months (stable)	<7.0% most adults	Intensify therapy; check adherence
Blood Pressure	Every visit	<130/80 mmHg	Add/intensify antihypertensive (ACEi/ARB first)
Weight / BMI	Every visit	≥5% loss for glycemic benefit	Intensify lifestyle; add GLP-1 RA/tirzepatide
Fasting Lipids	Annually (more if abnormal)	LDL <70 mg/dL (ASCVD)	Intensify statin; add ezetimibe → PCSK9i
eGFR + Serum Cr	Annually (more if CKD)	Monitor trajectory	Adjust medications; nephrology referral if eGFR <30
UACR	Annually	<30 mg/g	Start/intensify ACEi/ARB + SGLT2i; recheck ×2
Foot Exam	Annually (every visit if neuropathy)	No ulcer, no deformity	Podiatry referral; wound care; off-loading
Dilated Eye Exam	Annually (q2yr if stable)	No retinopathy	Ophthalmology referral; anti-VEGF if neovascular
Vitamin B12	Annually if on metformin ≥4 yrs	Normal range	Supplement orally or IM if deficient
Depression (PHQ-9)	Annually	PHQ-9 <5	Refer to mental health; adjust DM management
Smoking status	Every visit	Cessation	Cessation counseling + pharmacotherapy (varenicline)

Immunizations (Section 4)

Influenza: annually
COVID-19: per current CDC/ACIP recommendations
Pneumococcal: PCV15 or PCV20 + PPSV23 (if <65 yrs); booster at ≥65
Hepatitis B: unvaccinated adults < 60 years
Zoster (Shingrix): age ≥50 years (2-dose series)

When to Refer

Specialty	Indication
Endocrinology	A1C persistently >9%; complex insulin regimens; suspected monogenic DM
Ophthalmology	Annual dilated exam; any retinopathy detected
Nephrology	eGFR <30; rapid decline; significant proteinuria
Cardiology	Established CVD, HF, pre-surgical clearance
Podiatry	Peripheral neuropathy, foot ulcer, PAD, deformity
Dietitian / DSMES	At diagnosis; annually; medication intensification
Mental Health	PHQ-9 ≥10; diabetes distress; non-adherence

ADA 2026, Sections 4, 6, 10–12

SLIDE 20 — KEY TAKEAWAYS

8 High-Yield Clinical Pearls — ADA Standards of Care 2026

1. 📋 DIAGNOSE T2DM = A1C ≥6.5% OR FPG ≥126 mg/dL OR 2-h PG ≥200 mg/dL OR random PG ≥200 + symptoms. Confirm with 2 tests unless there is a classic hyperglycemic crisis.

2. 🔬 CLASSIFY CORRECTLY Use the AABBCC tool when T1 vs T2 is unclear. Misclassification occurs in up to 40% of adults with new-onset T1DM. Consider islet autoantibody testing (GAD, IA-2, ZnT8) when uncertain.

3. 💊 START PHARMACOTHERAPY EARLY Begin at diagnosis — do not delay. Metformin + lifestyle is the foundation for all T2DM patients unless contraindicated.

4. ❤️ PRIORITIZE CARDIORENAL PROTECTION In patients with established ASCVD, HF, or CKD → use GLP-1 RA or SGLT2i regardless of A1C level. These agents provide organ protection beyond glucose lowering.

5. 💉 GLP-1 RA BEFORE INSULIN For most T2DM adults not at glycemic goal and without severe hyperglycemia → GLP-1–based therapy is preferred over insulin (ADA Rec 9.21). If insulin is used, combine with GLP-1 RA for better outcomes (Rec 9.22).

6. ⛔ KNOW THE CONTRAINDICATIONS

Metformin: eGFR <30; hold with IV contrast
SGLT2i: T1DM; hold 3–4 days pre-surgery
GLP-1 RA / tirzepatide: MTC or MEN-2; hold before anesthesia
TZDs: HF Class III/IV; bladder cancer
Sulfonylureas: elderly/CKD → severe hypoglycemia

7. 📏 INDIVIDUALIZE GLYCEMIC TARGETS A1C <7.0% for most adults. Relax to ≤8.0–8.5% in frail elderly, limited life expectancy, recurrent severe hypoglycemia, or when the target is burdensome to achieve. Use CGM metrics (TIR >70%, TBR <4%) alongside A1C.

8. 🔄 MONITOR COMPREHENSIVELY AT EVERY VISIT A1C (or CGM) + BP + weight + lipids + eGFR + UACR + foot exam + dilated eye exam. Address weight, SDOH, DSMES, tobacco use, depression, and immunizations at every care interaction.

Source: American Diabetes Association Professional Practice Committee for Diabetes. Standards of Care in Diabetes — 2026. Diabetes Care 2026;49(Suppl. 1). https://doi.org/10.2337/dc26-SREV

All content sourced directly from ADA Standards of Care in Diabetes 2026, Sections 2, 4, 5, 6, 8, 9, 10, 11, 12, 13, 14, 15. For educational use only.

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