metformin dosing type 2 diabetes guidelines

metformin dosage titration maximum dose indication contraindications 2025 ADA guidelines

https://www.ncbi.nlm.nih.gov/books/NBK518983

ADA 2026 Standards of Medical Care Diabetes metformin dosage guidelines

ADA 2026 pharmacologic approaches glycemic treatment metformin section 9

https://sentucuman.com.ar/docs/standards-of-care-2026.pdf

ADA 2026 Standards Care metformin table 9.2 dosing contraindication eGFR site:diabetesjournals.org OR site:care.diabetesjournals.org

https://sentucuman.com.ar/docs/standards-of-care-2026.pdf

A clean, professional medical flowchart for Metformin (ADA 2026 Guidelines) with the following structure and content: Title at top: "METFORMIN - ADA 2026 Clinical Flowchart" FLOW: Box 1 (START - green): "Patient with Type 2 Diabetes or Indication for Metformin" Arrow down to Diamond 1 (yellow decision): "Any Contraindication Present?" From Diamond 1 - YES arrow right to Red Box: "CONTRAINDICATED - Do NOT Use Metformin" with list: - eGFR <30 mL/min/1.73 m² - Metabolic/lactic acidosis - Hepatic insufficiency - Severe hypoxemia - Hypersensitivity to metformin - Alcohol abuse - Unstable/hospitalized Heart Failure - Pregnancy (T2DM/GDM) From Diamond 1 - NO arrow down to Diamond 2 (yellow): "Check eGFR" From Diamond 2 - three arrows: - Arrow LEFT labeled "eGFR <30" → Red box: "STOP / Do Not Start" - Arrow MIDDLE labeled "eGFR 30-45" → Orange box: "Do NOT initiate. If already on it, reassess risk/benefit. Monitor every 3 months" - Arrow RIGHT labeled "eGFR 45-60" → Yellow box: "No dose adjustment. Monitor every 3-6 months" - Arrow DOWN labeled "eGFR >60" → Green box: "No adjustment. Monitor annually" All eGFR >45 paths merge down to Blue Box: "INITIATE METFORMIN" Two columns inside: LEFT - "Immediate-Release (IR): Start: 500 mg once or twice daily with meals | Titrate: +500 mg/week as tolerated | Maintenance: 1000-1500 mg twice daily | MAX: 2550 mg/day (2-3 divided doses)" RIGHT - "Extended-Release (ER): Start: 500-1000 mg once daily with evening meal | Titrate: +500 mg/week as tolerated | Maintenance: 1000-2000 mg once daily | MAX: 2000 mg/day" Arrow down to Purple Box: "MONITORING" - Vitamin B12: check if dose ≥1500 mg/day or >4-5 years use - eGFR: annually (more often if CKD) - GI side effects: mitigate with slow titration, ER form, food - No hypoglycemia risk as monotherapy Arrow down to Orange Box: "SPECIAL SITUATIONS - Hold/Discontinue" - Surgery: stop 3-4 days before - IV contrast (eGFR 30-60): hold at time of procedure, restart 48h after - Critical illness / prolonged fasting: hold - Unstable HF or hospitalization: hold Arrow down to Dark Blue Box: "CONTINUE METFORMIN WHEN…" - Starting insulin therapy - Adding SGLT2 inhibitors or GLP-1 RAs - Stable Heart Failure (if eGFR >30) Small box at bottom right labeled "NEW ADA 2026" in red: - Rec 3.8: Use to prevent PI3Kα inhibitor hyperglycemia - Rec 3.9: Use to prevent glucocorticoid-induced hyperglycemia - Rec 9.35a: First-line for mTOR/PI3K inhibitor hyperglycemia Use a white background, color-coded boxes (green=go, red=stop, yellow=caution, blue=action, purple=monitoring), clear arrows with labels, professional medical style, readable font sizes. Make it well-spaced and easy to follow.

ADA 2026 Standards Care SGLT2 inhibitors dosage titration indication contraindication table 9.2

SGLT2 inhibitors canagliflozin dapagliflozin empagliflozin ertugliflozin dosage ADA 2026 eGFR contraindications

http://saigaiin.sakura.ne.jp/sblo_files/saigaiin/image/DM20E…

https://www.ncbi.nlm.nih.gov/books/NBK576405

A clean, professional medical flowchart titled "SGLT2 INHIBITORS - ADA 2026 Clinical Flowchart" on a white background. Color-coded boxes with clear arrows. Professional medical style. Well-spaced and easy to follow. Layout from top to bottom: TOP - GREEN BOX (START): "Patient with T2DM or Comorbidity Indication for SGLT2 Inhibitor" Arrow down to YELLOW DIAMOND: "Any Absolute Contraindication?" YES arrow right → RED BOX "DO NOT USE SGLT2 Inhibitor: • Type 1 Diabetes (not approved) • Dialysis / ESKD • Serious hypersensitivity to agent • Active DKA or history of SGLT2-related DKA • Pregnancy / breastfeeding • Recurrent genital mycotic infections (relative)" NO arrow down → YELLOW DIAMOND: "Check eGFR" From eGFR diamond, 4 paths: LEFT path: "eGFR <20" → RED BOX "Stop/Do Not Initiate (glycemic benefit absent; consider only if continuing for CV/kidney benefit per individual agent label)" CENTER-LEFT: "eGFR 20-44" → ORANGE BOX "Glycemic benefit minimal. May START or CONTINUE canagliflozin, dapagliflozin, empagliflozin for CV/kidney protection (eGFR >20). Check individual agent label." CENTER-RIGHT: "eGFR 45-60" → YELLOW BOX "Full use permitted. Monitor eGFR every 3-6 months. Glycemic benefit reduced below 45." RIGHT path: "eGFR >60" → GREEN BOX "Full use. Monitor annually." All paths eGFR >20 merge → BLUE BOX "INDIVIDUAL AGENT DOSING (Once Daily, Morning, with or without food)" 4 columns: Column 1 - CANAGLIFLOZIN (Invokana): Start: 100 mg once daily | Titrate: Increase to 300 mg once daily if needed | Max: 300 mg/day | eGFR limit: <45 for glycemic use; may use ≥20 for CV/kidney Column 2 - DAPAGLIFLOZIN (Farxiga): Start: 5 mg once daily (T2DM) or 10 mg once daily (HF/CKD) | Titrate: Increase to 10 mg once daily | Max: 10 mg/day | eGFR limit: <45 for new initiation (glycemic); may continue ≥25 for kidney/CV Column 3 - EMPAGLIFLOZIN (Jardiance): Start: 10 mg once daily | Titrate: Increase to 25 mg once daily | Max: 25 mg/day | eGFR limit: ≥30 for glycemic; ≥20 for HF/CKD benefit Column 4 - ERTUGLIFLOZIN (Steglatro): Start: 5 mg once daily | Titrate: Increase to 15 mg once daily | Max: 15 mg/day | eGFR limit: <45 not recommended Arrow down → PURPLE BOX "INDICATIONS (ADA 2026)" • T2DM glycemic management (add-on or first-line with comorbidities) • ASCVD or high CV risk: canagliflozin, empagliflozin (MACE benefit) • Heart Failure (HFrEF & HFpEF): canagliflozin, dapagliflozin, empagliflozin, ertugliflozin • CKD (eGFR 20-60 and/or albuminuria): canagliflozin, dapagliflozin, empagliflozin • MASH (metabolic liver disease): dapagliflozin, empagliflozin - potential benefit • NEW ADA 2026 (Rec 11.9): Simultaneous SGLT2-i + nsMRA for T2DM with uACR ≥100 mg/g + eGFR 30-90 Arrow down → ORANGE BOX "HOLD / DISCONTINUE SITUATIONS" • Surgery: hold 3-4 days before major surgery or prolonged fasting • DKA risk: hold during critical illness, dehydration, very-low-carb diet • Iodinated contrast: hold on day of procedure • Hospitalization for acute illness: hold Arrow down → DARK BLUE BOX "ADVERSE EFFECTS TO MONITOR" • Genital mycotic infections (most common) — hygiene counseling • UTI / urosepsis / pyelonephritis — treat promptly • Necrotizing fasciitis (Fournier gangrene) — rare, urgent treatment • DKA (euglycemic) — educate on ketone monitoring; risk factors: T1D, fasting, alcohol, low-carb • Volume depletion / hypotension — adjust diuretics; monitor BP and renal function • Lower limb amputations — canagliflozin (monitor foot care) • Bone fractures — canagliflozin Small box bottom right labeled "DURATION" in dark green: "Long-term / indefinite — continue for CV and kidney benefit even as glucose-lowering effect diminishes at low eGFR. May continue until dialysis or transplantation (per individual agent)." Use white background, color-coded boxes, clear directional arrows with labels, readable fonts, professional clean medical layout.

ADA 2026 GLP-1 RA semaglutide dulaglutide liraglutide dosage titration maximum dose indication contraindication table 9.2

ADA 2026 tirzepatide GIP GLP-1 dual agonist dosage titration indication contraindication guidelines

https://pmc.ncbi.nlm.nih.gov/articles/PMC12690185

https://www.dralo.net/blog/diabetes-guidelines-2026

A large, clean, professional medical flowchart on white background titled "GLP-1 RAs & Dual GIP/GLP-1 RA (Tirzepatide) — ADA 2026 Clinical Flowchart". Two clearly separated color-coded sections side by side. Professional medical style with readable fonts, color-coded boxes, clear arrows. The chart has TWO PARALLEL COLUMNS after a shared top section: ===TOP SHARED SECTION=== GREEN START BOX (top center): "Patient with T2DM or Comorbidity Indication" Arrow down to YELLOW DIAMOND: "Any Absolute Contraindication?" YES → RED BOX (right): "DO NOT USE: • Personal/family history of MTC or MEN2 • Active pancreatitis or high-risk pancreatitis • Hypersensitivity to agent • Pregnancy (discontinue before conception) • Severe gastroparesis • Prior SGLT2-related DKA (for dual GIP/GLP-1 only) • BMI <18.5 kg/m² (stop if BMI drops below this)" NO → Arrow splits into TWO COLUMNS: ===LEFT COLUMN: GLP-1 RAs (SQ + Oral Semaglutide)=== Header box (TEAL/DARK CYAN): "GLP-1 RECEPTOR AGONISTS (SQ)" Sub-box labeled "INDIVIDUAL AGENT DOSING": Row 1 - SEMAGLUTIDE SQ (Ozempic) - Weekly: Start: 0.25 mg SC once weekly x 4 weeks Titrate: → 0.5 mg once weekly x 4 weeks → 1 mg once weekly (maintenance) → 2 mg once weekly if needed MAX: 2 mg/week SC Frequency: ONCE WEEKLY Row 2 - SEMAGLUTIDE ORAL (Rybelsus) - Daily: Start: 3 mg orally once daily x 30 days (fasting, 30 min before food) Titrate: → 7 mg once daily x 30 days → 14 mg once daily MAX: 14 mg/day Frequency: ONCE DAILY (morning, fasting) Row 3 - DULAGLUTIDE (Trulicity) - Weekly: Start: 0.75 mg SC once weekly Titrate: → 1.5 mg once weekly → 3 mg once weekly → 4.5 mg once weekly (every 4 weeks as needed) MAX: 4.5 mg/week SC Frequency: ONCE WEEKLY Row 4 - LIRAGLUTIDE (Victoza) - Daily: Start: 0.6 mg SC once daily x 1 week Titrate: → 1.2 mg once daily → 1.8 mg once daily MAX: 1.8 mg/day SC Frequency: ONCE DAILY Row 5 - EXENATIDE ER (Bydureon) - Weekly: Start and Maintenance: 2 mg SC once weekly (no titration) MAX: 2 mg/week TEAL BOX - INDICATIONS (GLP-1 RA): • T2DM glycemic management (A1C lowering 1-2%+) • ASCVD / high CV risk: dulaglutide, liraglutide, semaglutide SQ (MACE benefit) • CKD: albuminuria reduction - dulaglutide, liraglutide, semaglutide SQ • MASH/MASLD: semaglutide SQ (proven benefit) • Heart Failure prevention (Stage B): GLP-1 RA with HF prevention benefit • Dialysis: can initiate/continue GLP-1 RA for CV risk reduction • Obesity in T1DM (NEW ADA 2026): GLP-1 RA-based therapy now an option • Weight management (Wegovy - semaglutide 2.4 mg/wk) RENAL NOTE: No dose adjustment for dulaglutide, liraglutide, semaglutide. Monitor kidney function if severe GI reactions. ===RIGHT COLUMN: DUAL GIP/GLP-1 RA (Tirzepatide)=== Header box (PURPLE): "DUAL GIP AND GLP-1 RA — TIRZEPATIDE (Mounjaro / Zepbound)" Sub-box "DOSING": Start: 2.5 mg SC once weekly x 4 weeks Titrate: Increase by 2.5 mg every 4 weeks as tolerated: → 5 mg/week → 7.5 mg/week → 10 mg/week → 12.5 mg/week → 15 mg/week Maintenance: 5, 10, or 15 mg once weekly (individualize) MAX: 15 mg/week Frequency: ONCE WEEKLY (any day, with or without food) RENAL NOTE: No dose adjustment needed. Monitor kidney function if severe GI reactions. PURPLE BOX - INDICATIONS (Tirzepatide): • T2DM glycemic management (VERY HIGH efficacy; A1C lowering ≥2%) • ASCVD / high CV risk: benefit under investigation (positive SURPASS-CVOT) • HF: benefit for tirzepatide (HF events) • HFpEF with obesity (Stage C): preferred agent (NEW ADA 2026 Rec 9.9a/10.44d) • MASH/MASLD: potential benefit (Rec 9.12-9.13a) • Obesity (BMI ≥30 or ≥27 with comorbidity): Zepbound indication • Obesity in T1DM (NEW ADA 2026) ADA 2026 NOTE: "Optimal treatment dose may not be the maximum approved dose - individualize" ===BOTTOM SHARED SECTION (spans both columns)=== ORANGE BOX - "HOLD / DISCONTINUE": • Surgery / anesthesia: discontinue before procedure (risk of pulmonary aspiration) - timing per label • Pancreatitis suspected: discontinue immediately • Severe GI intolerance: slow titration or hold • Pregnancy: discontinue (washout period varies by agent) • BMI drops below 18.5 kg/m²: stop DARK BLUE BOX - "MONITOR FOR": • GI side effects (nausea, vomiting, diarrhea) — most common; counsel on dietary modifications (smaller meals, slow eating, avoid high-fat/spicy food); slower titration for sensitive patients • Pancreatitis — evaluate abdominal pain; discontinue if suspected • Biliary disease (cholelithiasis, cholecystitis) — evaluate if suspected; avoid in high-risk • Diabetic retinopathy progression — close monitoring if high risk (long T2DM duration ≥10 years, older age); consider slower semaglutide/tirzepatide titration • NAION (nonarteritic anterior ischemic optic neuropathy) — rare; monitor during eye exams • Drug absorption interactions — oral medications (including oral contraceptives) may be affected during dose titration DURATION BOX (green): "Long-term / indefinite — continue for CV, kidney, liver, and weight benefits. Titration duration: typically 12-20 weeks to reach maintenance dose." White background, well-spaced, large readable text, color-coded headers, professional clean medical layout.

A very large, tall, professional medical reference poster on white background combining TWO complete clinical flowcharts stacked vertically. Both charts share the same professional style, color scheme, and formatting. Clean, readable fonts. All text must be legible. ======================================== TOP HALF — CHART 1 ======================================== TITLE (large dark blue bold): "METFORMIN — ADA 2026 Clinical Flowchart" LEFT SIDE - FLOWCHART PATH: GREEN box (START): "START — Patient with Type 2 Diabetes or Indication for Metformin" Arrow down to YELLOW DIAMOND: "Any Contraindication Present?" From diamond: - YES → thick red arrow RIGHT to RED box: "CONTRAINDICATED — Do NOT Use Metformin • eGFR <30 mL/min/1.73 m² • Hypersensitivity • Metabolic/lactic acidosis • Alcohol abuse • Hepatic insufficiency • Unstable/hospitalized Heart Failure • Severe hypoxemia • Pregnancy (T2DM/GDM) • Hypersensitivity to metformin" - NO → green arrow down to YELLOW DIAMOND: "Check eGFR" From eGFR diamond, 3 paths: - LEFT arrow "eGFR <30" → RED box: "STOP / Do Not Start" - MIDDLE arrow "eGFR 30-45" → ORANGE box: "Do NOT initiate. If already on it, reassess risk/benefit. Monitor every 3 months" - RIGHT arrow "eGFR 45-60" → YELLOW box: "No dose adjustment. Monitor every 3-6 months" - DOWN arrow "eGFR >60" → GREEN box: "No adjustment. Monitor annually" All eGFR >30 paths merge to BLUE box: "INITIATE METFORMIN Immediate-Release (IR): Start: 500 mg once or twice daily with meals | Titrate: +500 mg/week as tolerated | Maintenance: 1000-1500 mg twice daily | MAX: 2550 mg/day (2-3 divided doses) Extended-Release (ER): Start: 500-1000 mg once daily with evening meal | Titrate: +500 mg/week as tolerated | Maintenance: 1000-2000 mg once daily | MAX: 2000 mg/day" Arrow down to PURPLE box: "MONITORING • Vitamin B12: check if dose ≥1500 mg/day or >4-5 years use • eGFR: annually (more often if CKD) • GI side effects: mitigate with slow titration, ER form, food • No hypoglycemia risk as monotherapy" Arrow down to ORANGE box: "SPECIAL SITUATIONS — Hold/Discontinue • Surgery: stop 3-4 days before • IV contrast (eGFR 30-60): hold at time of procedure, restart 48h after • Critical illness / prolonged fasting: hold • Unstable HF or hospitalization: hold" Arrow down, splits to TWO boxes side by side: LEFT DARK BLUE box: "CONTINUE METFORMIN WHEN… • Starting insulin therapy • Adding SGLT2 inhibitors or GLP-1 RAs • Stable Heart Failure (if eGFR >30)" RIGHT RED-BORDERED box labeled "NEW ADA 2026": "• Rec 3.8: Use to prevent PI3Kα inhibitor hyperglycemia • Rec 3.9: Use to prevent glucocorticoid-induced hyperglycemia • Rec 9.35a: First-line for mTOR/PI3K inhibitor hyperglycemia" THICK HORIZONTAL DIVIDER LINE between Chart 1 and Chart 2 ======================================== BOTTOM HALF — CHART 2 ======================================== TITLE (large dark navy bold): "SGLT2 INHIBITORS — ADA 2026 Clinical Flowchart" GREEN box (START): "START — Patient with T2DM or Comorbidity Indication for SGLT2 Inhibitor" Arrow down to YELLOW DIAMOND: "Any Absolute Contraindication?" YES → RED box: "DO NOT USE SGLT2 Inhibitor: • Type 1 Diabetes (not approved) • Dialysis / ESKD • Serious hypersensitivity to agent • Active DKA or history of SGLT2-related DKA • Pregnancy / breastfeeding • Recurrent genital mycotic infections (relative)" NO → down to YELLOW DIAMOND: "Check eGFR" From eGFR diamond, 4 paths: - "eGFR <20" → RED box: "Stop/Do Not Initiate (glycemic benefit absent; consider only if continuing for CV/kidney benefit per individual agent label)" - "eGFR 20-44" → ORANGE box: "Glycemic benefit minimal. May START or CONTINUE canagliflozin, dapagliflozin, empagliflozin for CV/kidney protection (eGFR >20). Check individual agent label." - "eGFR 45-60" → YELLOW box: "Full use permitted. Monitor eGFR every 3-6 months. Glycemic benefit reduced below 45." - "eGFR >60" → GREEN box: "Full use. Monitor annually." All eGFR >20 paths merge to DARK BLUE box: "INDIVIDUAL AGENT DOSING (Once Daily, Morning, with or without food) CANAGLIFLOZIN (Invokana): Start: 100 mg once daily | Titrate: Increase to 300 mg if needed | Max: 300 mg/day | eGFR: <45 for glycemic use; ≥20 for CV/kidney DAPAGLIFLOZIN (Farxiga): Start: 5 mg (T2DM) or 10 mg (HF/CKD) once daily | Titrate: Increase to 10 mg | Max: 10 mg/day | eGFR: <45 do not initiate (glycemic); may continue ≥25 for kidney/CV EMPAGLIFLOZIN (Jardiance): Start: 10 mg once daily | Titrate: Increase to 25 mg | Max: 25 mg/day | eGFR: ≥30 for glycemic; ≥20 for HF/CKD ERTUGLIFLOZIN (Steglatro): Start: 5 mg once daily | Titrate: Increase to 15 mg | Max: 15 mg/day | eGFR: <45 not recommended" Arrow down to TEAL box: "INDICATIONS (ADA 2026) • T2DM glycemic management (add-on or first-line with comorbidities) • ASCVD / high CV risk: canagliflozin, empagliflozin (MACE benefit) • Heart Failure (HFrEF & HFpEF): canagliflozin, dapagliflozin, empagliflozin, ertugliflozin • CKD (eGFR 20-60 and/or albuminuria): canagliflozin, dapagliflozin, empagliflozin • MASH (metabolic liver disease): dapagliflozin, empagliflozin — potential benefit • NEW ADA 2026 (Rec 11.9): Simultaneous SGLT2-i + nsMRA for T2DM with uACR ≥100 mg/g + eGFR 30-90" Arrow down to ORANGE box: "HOLD / DISCONTINUE SITUATIONS • Surgery: hold 3-4 days before major surgery or prolonged fasting • DKA risk: hold during critical illness, dehydration, very-low-carb diet • Iodinated contrast: hold on day of procedure • Hospitalization for acute illness: hold" Arrow down to wide box split into two sections: LEFT DARK BLUE section: "ADVERSE EFFECTS TO MONITOR • Genital mycotic infections (most common) — hygiene counseling • UTI / urosepsis / pyelonephritis — treat promptly • Necrotizing fasciitis (Fournier gangrene) — rare, urgent treatment • DKA (euglycemic) — educate on ketone monitoring; risk factors: T1D, fasting, alcohol, low-carb • Volume depletion / hypotension — adjust diuretics; monitor BP and renal function • Lower limb amputations — canagliflozin (monitor foot care) • Bone fractures — canagliflozin" RIGHT DARK GREEN section: "DURATION Long-term / indefinite — continue for CV and kidney benefit even as glucose-lowering effect diminishes at low eGFR. May continue until dialysis or transplantation (per individual agent)." Use: white background throughout, color-coded boxes exactly as described (green=start/go, red=stop/contraindication, yellow=caution/decision, orange=warning/hold, blue=dosing/action, purple=monitoring, teal=indications, dark navy=headers), clear directional arrows, bold section titles, clean professional medical poster layout. Make all text clearly readable. The image should be very tall to accommodate both complete flowcharts.

ADA 2026 DPP-4 inhibitors sitagliptin saxagliptin linagliptin alogliptin dosage titration maximum dose indication contraindication table 9.2

ADA 2026 pioglitazone sulfonylureas glipizide glimepiride glyburide dosage titration maximum dose contraindication table 9.2

https://pmc.ncbi.nlm.nih.gov/articles/PMC12690185

sitagliptin saxagliptin linagliptin alogliptin dose renal adjustment eGFR pioglitazone dose maximum glipizide glimepiride dosing 2025 2026

A very large, tall professional medical reference poster on white background combining TWO complete clinical flowcharts stacked vertically with a thick dividing line between them. Clean, readable fonts, color-coded boxes, clear directional arrows. Professional medical style. ======================================== TOP HALF — CHART 1: DPP-4 INHIBITORS ======================================== TITLE (large dark blue bold text, centered): "DPP-4 INHIBITORS — ADA 2026 Clinical Flowchart" LEFT FLOWCHART PATH: GREEN START BOX: "START — Patient with T2DM — Consider DPP-4 Inhibitor" Arrow down to YELLOW DIAMOND: "Any Contraindication?" YES arrow → RED BOX: "DO NOT USE / CAUTION: • History of pancreatitis (do not initiate) • Serious hypersensitivity to agent • Saxagliptin: avoid in heart failure (potential risk) • Avoid DPP-4i + GLP-1 RA combination (no added benefit) • Heart failure: saxagliptin associated with increased HF hospitalizations • Severe hepatic impairment (alogliptin)" NO arrow → YELLOW DIAMOND: "Check eGFR" eGFR paths: "eGFR ≥45" → GREEN box: "Full dose — no adjustment needed for any agent" "eGFR 30-44" → YELLOW box: "Reduce sitagliptin to 50 mg/day | Reduce saxagliptin to 2.5 mg/day | Reduce alogliptin to 12.5 mg/day | Linagliptin: NO adjustment" "eGFR <30 or dialysis" → ORANGE box: "Reduce sitagliptin to 25 mg/day | Saxagliptin: 2.5 mg/day (not recommended in HD) | Reduce alogliptin to 6.25 mg/day | Linagliptin: NO adjustment — preferred agent in CKD" All paths merge → BLUE DOSING BOX: "INDIVIDUAL AGENT DOSING (Once Daily, With or Without Food) SITAGLIPTIN (Januvia): 100 mg once daily | Renal: 50 mg (eGFR 30-44); 25 mg (eGFR <30/dialysis) | MAX: 100 mg/day SAXAGLIPTIN (Onglyza): 2.5 mg or 5 mg once daily | Renal: 2.5 mg if eGFR <45 | MAX: 5 mg/day | Avoid in HF LINAGLIPTIN (Tradjenta): 5 mg once daily | NO renal adjustment needed | MAX: 5 mg/day — PREFERRED in CKD ALOGLIPTIN (Nesina): 25 mg once daily | Renal: 12.5 mg (eGFR 30-59); 6.25 mg (eGFR <30/dialysis) | MAX: 25 mg/day" TEAL INDICATIONS BOX: "INDICATIONS (ADA 2026) • T2DM glycemic management (add-on therapy) — A1C lowering ~0.7-1.0% • Patients at risk for hypoglycemia (no hypoglycemia risk as monotherapy) • Weight-neutral option when weight gain undesirable • Post-transplant: DPP-4i for mild hyperglycemia (Rec 9.37 — NEW ADA 2026) • Preferred in frailty and older adults (NICE/ADA) • Note: Do NOT combine with GLP-1 RA — no added benefit" PURPLE MONITORING BOX: "ADVERSE EFFECTS & MONITORING • Pancreatitis: reported but causality unestablished; discontinue if suspected • Joint pain (arthralgia): consider discontinuing if debilitating • Bullous pemphigoid: discontinue if suspected — reversible • Saxagliptin: increased HF hospitalization risk — avoid in HF patients • Renal function: monitor periodically for dose adjustments" THICK DIVIDING LINE ======================================== BOTTOM HALF — CHART 2: PIOGLITAZONE & SULFONYLUREAS ======================================== TITLE (large dark maroon bold, centered): "PIOGLITAZONE & SULFONYLUREAS — ADA 2026 Clinical Flowchart" TWO SIDE-BY-SIDE COLUMNS: LEFT COLUMN — PIOGLITAZONE (Actos) — Header in DARK TEAL: GREEN START: "Patient with T2DM — Consider Pioglitazone" YELLOW DIAMOND: "Any Contraindication?" YES → RED BOX: "DO NOT USE: • Active Heart Failure (NYHA Class III-IV) — increased HF risk and fluid retention • Active bladder cancer • Caution: prior history of bladder cancer • Severe hepatic impairment • Osteoporosis / high fracture risk • Pregnancy" NO → BLUE DOSING BOX: "PIOGLITAZONE DOSING (Once Daily, With or Without Food): Start: 15 mg or 30 mg once daily Titrate: Increase by 15 mg every 4-8 weeks as tolerated MAX: 45 mg/day Renal: Generally not recommended in kidney impairment due to potential for fluid retention Frequency: ONCE DAILY" ORANGE INDICATIONS BOX: "INDICATIONS (ADA 2026) • T2DM glycemic management — HIGH efficacy (A1C reduction similar to metformin) • MASH/biopsy-proven MASH — potential benefit (Rec 9.13a — ADA 2026) • Insulin-sparing: adjunctive to insulin (reduces insulin dose needed) • Cardiovascular: potential benefit (PROactive trial data)" PURPLE ADVERSE EFFECTS: "MONITOR: • Fluid retention / edema — dose-related; avoid in HF • Weight gain — significant (3-4 kg average) • Heart failure risk — increased; do not use in HF • Bone fractures — increased risk (especially women) • Bladder cancer — do not use if active; caution if prior history • Hepatotoxicity — monitor LFTs" RIGHT COLUMN — SULFONYLUREAS (2nd Generation) — Header in DARK RED: GREEN START: "Patient with T2DM — Consider Sulfonylurea" YELLOW DIAMOND: "Any Contraindication?" YES → RED BOX: "DO NOT USE / CAUTION: • Glyburide: generally NOT recommended in CKD • Sulfa allergy (all agents) • Type 1 Diabetes / DKA • Pregnancy (insulin preferred) • Severe hepatic or renal impairment • High hypoglycemia risk (elderly, frail, irregular meals)" NO → BLUE DOSING BOX: "INDIVIDUAL SULFONYLUREA DOSING (With Meals) GLIPIZIDE (Glucotrol): Start: 5 mg once daily before breakfast | Titrate: +2.5-5 mg/week | MAX: 40 mg/day IR (20 mg/day XL) | Frequency: 1-2x daily (XL once daily) GLIMEPIRIDE (Amaryl): Start: 1-2 mg once daily with first meal | Titrate: +1-2 mg every 1-2 weeks | MAX: 8 mg/day | Frequency: ONCE DAILY GLYBURIDE (DiaBeta): Start: 2.5-5 mg once daily with breakfast | Titrate: +2.5 mg/week | MAX: 20 mg/day | Frequency: 1-2x daily | AVOID in CKD" TEAL INDICATIONS BOX: "INDICATIONS (ADA 2026) • T2DM glycemic management — HIGH efficacy (A1C reduction 1-2%) • Cost-effective option when affordability is a priority • Glimepiride: CV-safe (shown non-inferior in CAROLINA trial) • Note ADA 2026: Limit/discontinue SU when GLP-1 RA or SGLT2-i initiated — no added CV/kidney/weight benefit" ORANGE RENAL DOSING BOX: "RENAL CONSIDERATIONS (ADA 2026): • Glyburide: GENERALLY NOT RECOMMENDED in CKD (active metabolite accumulates — hypoglycemia risk) • Glipizide: PREFERRED sulfonylurea in CKD — initiate conservatively • Glimepiride: Use conservatively in CKD — initiate at 1 mg/day; monitor closely • All: Initiate at lowest dose to avoid hypoglycemia in renal impairment" PURPLE ADVERSE EFFECTS: "MONITOR: • Hypoglycemia — YES (significant risk, especially with insulin combination) • Weight gain — significant • FDA warning: increased CV mortality (older sulfonylurea tolbutamide); glimepiride shown CV-safe • Avoid in combination with insulin without careful dose reduction" BOTTOM FOOTER BOX (spans full width, dark navy): "ADA 2026 KEY POSITION: DPP-4 inhibitors, sulfonylureas, and pioglitazone are considered second-line or adjunctive agents. When GLP-1 RAs or SGLT2 inhibitors are initiated, ADA 2026 recommends limiting or discontinuing DPP-4i and sulfonylureas as they provide no additional CV, kidney, weight, or liver benefit. Pioglitazone may be continued adjunctively for MASH or insulin-sparing benefit." White background, professional medical poster, color-coded sections, bold headers, readable text, clear arrows. Very tall image to fit all content.

DPP-4 inhibitors sitagliptin saxagliptin linagliptin alogliptin dosage titration renal adjustment ADA 2026

pioglitazone sulfonylureas glipizide glimepiride glyburide dosage titration maximum dose contraindication ADA 2026 CKD

A very large professional medical reference poster on white background with THREE complete clinical flowcharts arranged as follows: TOP section = DPP-4 Inhibitors, MIDDLE section = Pioglitazone, BOTTOM section = Sulfonylureas 2nd Generation. Separated by thick colored divider lines. Color-coded boxes, clear arrows, bold headings, clean readable fonts. Professional medical style. ======================================== TOP SECTION — DPP-4 INHIBITORS ======================================== LARGE DARK BLUE TITLE: "DPP-4 INHIBITORS (Oral) — ADA 2026 Clinical Flowchart" GREEN START BOX: "START — Patient with T2DM — Consider DPP-4 Inhibitor" Arrow down → YELLOW DIAMOND: "Any Contraindication?" YES → RED BOX (right): "DO NOT USE / CAUTION: • Hypersensitivity to specific agent • Personal or family history of pancreatitis (avoid / high caution) • Saxagliptin: avoid in Heart Failure — associated with increased HF hospitalization risk • DO NOT combine with GLP-1 RA — no added glycemic benefit • Severe hepatic impairment (alogliptin: use caution)" NO → down → YELLOW DIAMOND: "Check eGFR" Three arrows from eGFR diamond: "eGFR ≥45" → GREEN box: "Full dose — no adjustment for any agent" "eGFR 30-44" → YELLOW/ORANGE box: "Sitagliptin → 50 mg once daily Saxagliptin → 2.5 mg once daily Alogliptin → 12.5 mg once daily Linagliptin → 5 mg once daily (NO change)" "eGFR <30 / Dialysis" → ORANGE box: "Sitagliptin → 25 mg once daily Saxagliptin → 2.5 mg once daily (not ideal in HD) Alogliptin → 6.25 mg once daily Linagliptin → 5 mg once daily (PREFERRED in CKD — NO adjustment)" All paths merge → BLUE DOSING BOX: "INDIVIDUAL AGENT DOSING — Once Daily, With or Without Food SITAGLIPTIN (Januvia): Start & Maintenance: 100 mg once daily | MAX: 100 mg/day | Renal: 50 mg (eGFR 30-44); 25 mg (eGFR <30/dialysis) SAXAGLIPTIN (Onglyza): Start: 2.5-5 mg once daily | MAX: 5 mg/day | Renal: 2.5 mg if eGFR <45 | AVOID in heart failure LINAGLIPTIN (Tradjenta): 5 mg once daily | MAX: 5 mg/day | NO renal adjustment — PREFERRED in CKD ALOGLIPTIN (Nesina): 25 mg once daily | MAX: 25 mg/day | Renal: 12.5 mg (eGFR 30-59); 6.25 mg (eGFR <30/dialysis) No titration needed for any DPP-4 inhibitor — fixed doses" TEAL INDICATIONS BOX: "INDICATIONS (ADA 2026) • T2DM glycemic management as add-on therapy (A1C lowering ~0.7-1.0%) • Weight-neutral option — no hypoglycemia risk as monotherapy • Preferred in frailty and older adults (minimal side effects, once-daily dosing) • Post-transplant: DPP-4i recommended for mild hyperglycemia (NEW ADA 2026 Rec 9.37) • Useful when GLP-1 RA not tolerated or affordable • ADA 2026: Limit/discontinue DPP-4i when GLP-1 RA started (no added CV/kidney/weight benefit)" PURPLE ADVERSE EFFECTS BOX: "ADVERSE EFFECTS TO MONITOR • Pancreatitis: reported; causality not established — discontinue if suspected • Joint pain (arthralgia): consider discontinuing if debilitating • Bullous pemphigoid: discontinue if suspected — reversible on discontinuation • Saxagliptin: increased HF hospitalization risk — avoid in HF patients • Nasopharyngitis and upper respiratory tract infections: common class effect • Duration: Long-term / indefinite as needed for glycemic control" THICK RED DIVIDER LINE ======================================== MIDDLE SECTION — PIOGLITAZONE ======================================== LARGE DARK TEAL TITLE: "PIOGLITAZONE (Oral — Thiazolidinedione) — ADA 2026 Clinical Flowchart" GREEN START BOX: "START — Patient with T2DM — Consider Pioglitazone" Arrow → YELLOW DIAMOND: "Any Contraindication?" YES → RED BOX: "DO NOT USE: • Active Heart Failure (any class) — increased HF risk and fluid retention • Active bladder cancer — absolute contraindication • Prior bladder cancer — use with caution (higher cumulative dose/duration = higher risk) • Severe hepatic impairment (ALT >2.5x ULN) • Pregnancy • Osteoporosis / high fracture risk — increased bone fracture risk • Edema / fluid overload states" NO → BLUE DOSING BOX: "PIOGLITAZONE DOSING — Once Daily, With or Without Food Start: 15 mg or 30 mg once daily Titrate: Increase by 15 mg every 8-12 weeks as tolerated and based on glycemic response Maintenance: 30-45 mg once daily MAX: 45 mg/day Frequency: ONCE DAILY Renal: Generally NOT recommended in kidney impairment — risk of fluid retention and edema Duration: Long-term as tolerated; benefits accumulate over months" TEAL INDICATIONS BOX: "INDICATIONS (ADA 2026) • T2DM glycemic management — HIGH efficacy (A1C reduction 1-1.5%) • MASH / Biopsy-proven MASH or high risk for liver fibrosis — potential benefit (ADA 2026 Rec 9.13a) • Adjunct to insulin — reduces insulin dose requirement • Cardiovascular: potential benefit (PROactive trial) • Alternative when GLP-1 RA/SGLT2-i not available or not tolerated" ORANGE ADVERSE EFFECTS BOX: "ADVERSE EFFECTS TO MONITOR • Fluid retention / peripheral edema — dose-related; avoid in HF • Weight gain — significant (2-4 kg) • Heart failure risk — increased; do NOT use in active HF • Bone fractures — increased risk, especially postmenopausal women • Bladder cancer — do not use if active; caution with longer use / higher doses • Monitor LFTs before initiating and periodically" THICK DARK RED DIVIDER LINE ======================================== BOTTOM SECTION — SULFONYLUREAS (2nd GENERATION) ======================================== LARGE DARK MAROON TITLE: "SULFONYLUREAS — 2nd Generation (Oral) — ADA 2026 Clinical Flowchart" GREEN START BOX: "START — Patient with T2DM — Consider Sulfonylurea" Arrow → YELLOW DIAMOND: "Any Contraindication?" YES → RED BOX: "DO NOT USE / CAUTION: • Type 1 Diabetes / DKA • Sulfa drug allergy (cross-reactivity possible) • Glyburide: generally NOT recommended in CKD — active metabolite accumulates → hypoglycemia • Pregnancy — insulin preferred • Severe hepatic impairment • Elderly / frail patients with irregular meals — high hypoglycemia risk • Combination with insulin — extreme hypoglycemia risk (reduce both doses) • ADA 2026: Fracture risk — avoid in patients with elevated fracture likelihood (TZDs and SUs)" NO → BLUE DOSING BOX (3 columns): "GLIPIZIDE (Glucotrol / Glucotrol XL) — With meals: IR: Start: 5 mg once daily (2.5 mg in elderly/liver disease) Titrate: +2.5-5 mg every several days MAX: 40 mg/day IR (doses >15 mg divide into 2 doses before meals) XL: Start: 5 mg once daily | MAX: 20 mg/day Frequency: IR 1-2x daily; XL once daily (with breakfast) CKD: PREFERRED sulfonylurea in CKD — initiate conservatively GLIMEPIRIDE (Amaryl) — With first meal of day: Start: 1-2 mg once daily Titrate: +1-2 mg every 1-2 weeks Maintenance: 1-4 mg once daily MAX: 8 mg/day Frequency: ONCE DAILY (with first meal) CKD: Start 1 mg/day; initiate conservatively; monitor closely CV: Shown CV-safe (CAROLINA trial vs linagliptin) GLYBURIDE (DiaBeta / Micronase) — With breakfast or first meal: Start: 2.5-5 mg once daily Titrate: +2.5 mg/week MAX: 20 mg/day (micronized: 12 mg/day) Frequency: 1-2x daily with meals CKD: GENERALLY NOT RECOMMENDED — active metabolite accumulates" TEAL INDICATIONS BOX: "INDICATIONS (ADA 2026) • T2DM glycemic management — HIGH efficacy (A1C reduction 1-2%) • Cost-effective option when affordability is a concern (lowest drug cost) • Glimepiride: CV-safe option (CAROLINA trial showed non-inferiority vs linagliptin) • Short-term glycemic coverage during illness/transitions • ADA 2026 NOTE: Limit/discontinue sulfonylureas when GLP-1 RA or SGLT2-i started — SUs provide no additional CV, kidney, weight, or liver benefit and increase hypoglycemia and weight gain risk" ORANGE ADVERSE EFFECTS BOX: "ADVERSE EFFECTS TO MONITOR • Hypoglycemia — YES (significant; most common serious adverse effect) • Weight gain — significant (1-4 kg) • FDA Special Warning: Increased CV mortality based on tolbutamide studies (older generation) • Glimepiride: shown CV-safe in CAROLINA trial • Avoid/reduce dose when combining with insulin • ADA 2026: Avoid in patients with elevated fracture risk (TZDs and SUs — increased fracture risk recommendation)" BOTTOM WIDE NAVY FOOTER BOX: "ADA 2026 KEY POSITION: DPP-4 inhibitors, sulfonylureas, and pioglitazone are second-line or adjunctive agents. When GLP-1 RA or SGLT2-i are initiated (preferred for CV/kidney/weight benefit), ADA 2026 recommends limiting or discontinuing DPP-4 inhibitors and sulfonylureas. Pioglitazone may be retained for MASH or insulin-sparing benefit. Glipizide or glimepiride are preferred over glyburide in CKD." White background, color-coded boxes (green=start, red=contraindication, yellow=decision/caution, orange=hold/adverse, blue=dosing, teal=indications, purple=monitoring, navy=footer), clear arrows, bold readable text, professional clinical layout. Very tall image to fit all three sections.

A very large tall professional medical reference poster on white background with THREE stacked clinical flowcharts separated by thick colored divider lines. Color-coded boxes, clear arrows, bold headings, readable fonts throughout. Professional clinical style. ═══════════════════════════════════════ SECTION 1 — DPP-4 INHIBITORS ═══════════════════════════════════════ TITLE (large, dark blue bold, centered): "DPP-4 INHIBITORS (Oral) — ADA 2026" GREEN BOX: "START: Patient with T2DM — Consider DPP-4 Inhibitor" ↓ YELLOW DIAMOND: "Any Contraindication?" YES → RED BOX: "DO NOT USE: • Hypersensitivity to agent • Saxagliptin: avoid in Heart Failure (increased HF hospitalization risk) • Do NOT combine with GLP-1 RA (no added benefit) • Pancreatitis history: high caution • Severe hepatic impairment (alogliptin)" NO → YELLOW DIAMOND: "Check eGFR" → eGFR ≥45: GREEN box "Full dose all agents" → eGFR 30–44: YELLOW box "Sitagliptin 50 mg | Saxagliptin 2.5 mg | Alogliptin 12.5 mg | Linagliptin 5 mg (unchanged)" → eGFR <30 / Dialysis: ORANGE box "Sitagliptin 25 mg | Saxagliptin 2.5 mg (avoid HD) | Alogliptin 6.25 mg | Linagliptin 5 mg (PREFERRED — no adjustment)" All paths → BLUE BOX: "DOSING — Once Daily, With or Without Food (No Titration Required) • SITAGLIPTIN (Januvia): 100 mg once daily | MAX: 100 mg/day • SAXAGLIPTIN (Onglyza): 2.5–5 mg once daily | MAX: 5 mg/day | Avoid HF • LINAGLIPTIN (Tradjenta): 5 mg once daily | MAX: 5 mg/day | NO renal adjustment — preferred in CKD • ALOGLIPTIN (Nesina): 25 mg once daily | MAX: 25 mg/day" TEAL BOX: "INDICATIONS (ADA 2026) • T2DM add-on glycemic management (A1C ↓ ~0.7–1.0%) • No hypoglycemia risk as monotherapy — weight neutral • Preferred in frailty / older adults • Post-transplant mild hyperglycemia (NEW Rec 9.37, ADA 2026) • ADA 2026: Limit/discontinue when GLP-1 RA started — no added CV/kidney/weight benefit" PURPLE BOX: "ADVERSE EFFECTS • Pancreatitis: reported; discontinue if suspected • Joint pain (arthralgia): discontinue if debilitating • Bullous pemphigoid: discontinue if suspected — reversible • Saxagliptin: ↑ HF hospitalization — avoid in HF • Duration: Long-term as needed" THICK RED HORIZONTAL DIVIDER LINE ═══════════════════════════════════════ SECTION 2 — PIOGLITAZONE ═══════════════════════════════════════ TITLE (large dark teal bold, centered): "PIOGLITAZONE — Thiazolidinedione (Oral) — ADA 2026" GREEN BOX: "START: Patient with T2DM — Consider Pioglitazone" ↓ YELLOW DIAMOND: "Any Contraindication?" YES → RED BOX: "DO NOT USE: • Active Heart Failure (any class) — ↑ HF risk and fluid retention • Active bladder cancer — absolute contraindication • Prior bladder cancer — caution (higher cumulative dose/duration = higher risk) • Osteoporosis / high fracture risk — increased bone fracture risk • Severe hepatic impairment • Pregnancy • Significant edema / fluid overload • Kidney impairment — generally NOT recommended (fluid retention)" NO → BLUE BOX: "PIOGLITAZONE DOSING — Once Daily, With or Without Food • Start: 15–30 mg once daily • Titrate: Increase by 15 mg every 8–12 weeks based on response • Maintenance: 30–45 mg once daily • MAX: 45 mg/day • Frequency: ONCE DAILY • Renal: Generally NOT recommended in CKD — fluid retention risk • Duration: Long-term as tolerated; months needed to see full glycemic effect" TEAL BOX: "INDICATIONS (ADA 2026) • T2DM glycemic management — HIGH efficacy (A1C ↓ ~1–1.5%) • MASH / Biopsy-proven MASH or high liver fibrosis risk — Rec 9.13a (ADA 2026) • Adjunct to insulin — reduces insulin dose requirement • Cardiovascular: potential benefit (PROactive trial data) • Alternative when GLP-1 RA / SGLT2-i not available or not tolerated" ORANGE BOX: "ADVERSE EFFECTS TO MONITOR • Fluid retention / peripheral edema — dose-related • Weight gain — significant (2–4 kg) • Heart failure — increased risk; do NOT use in active HF • Bone fractures — increased risk (especially postmenopausal women) • Bladder cancer — avoid if active; caution with long-term high-dose use • Monitor LFTs before starting and periodically • ADA 2026: Avoid in elevated fracture risk patients (TZDs and SUs both flagged)" THICK DARK MAROON HORIZONTAL DIVIDER LINE ═══════════════════════════════════════ SECTION 3 — SULFONYLUREAS (2nd GENERATION) ═══════════════════════════════════════ TITLE (large dark maroon bold, centered): "SULFONYLUREAS — 2nd Generation (Oral) — ADA 2026" GREEN BOX: "START: Patient with T2DM — Consider Sulfonylurea" ↓ YELLOW DIAMOND: "Any Contraindication?" YES → RED BOX: "DO NOT USE / CAUTION: • Type 1 Diabetes or DKA • Sulfa drug allergy • Glyburide: GENERALLY NOT RECOMMENDED in CKD (active metabolite accumulates → hypoglycemia) • Pregnancy — use insulin instead • Severe hepatic impairment • Elderly / frail / irregular meals — high hypoglycemia risk • Combination with insulin: extreme hypoglycemia caution • ADA 2026: Avoid in patients with elevated fracture risk" NO → THREE-COLUMN BLUE BOX: "INDIVIDUAL AGENT DOSING (With Meals) GLIPIZIDE (Glucotrol): IR: Start 5 mg once daily before breakfast (2.5 mg elderly/liver) Titrate: +2.5–5 mg every few days MAX IR: 40 mg/day (divide doses >15 mg) XL: Start 5 mg once daily | MAX: 20 mg/day Frequency: IR 1–2x daily | XL once daily CKD: PREFERRED — initiate conservatively GLIMEPIRIDE (Amaryl): Start: 1–2 mg once daily with first meal Titrate: +1–2 mg every 1–2 weeks Maintenance: 1–4 mg once daily MAX: 8 mg/day Frequency: ONCE DAILY with first meal CKD: Start 1 mg; initiate conservatively CV: CAROLINA trial — proven CV safety vs linagliptin GLYBURIDE (DiaBeta): Start: 2.5–5 mg once daily with breakfast Titrate: +2.5 mg/week MAX: 20 mg/day (micronized: 12 mg/day) Frequency: 1–2x daily with meals CKD: GENERALLY NOT RECOMMENDED" TEAL BOX: "INDICATIONS (ADA 2026) • T2DM glycemic management — HIGH efficacy (A1C ↓ 1–2%) • Most cost-effective oral agent • Glimepiride: CV-safe (CAROLINA trial) • Short-term glycemic coverage during transitions or illness • ADA 2026: Limit/discontinue when GLP-1 RA or SGLT2-i started — no added CV/kidney/weight/liver benefit; increase hypoglycemia and weight gain risk" ORANGE BOX: "ADVERSE EFFECTS TO MONITOR • Hypoglycemia — YES (most significant risk; especially in elderly, renal impairment, combination with insulin) • Weight gain — significant (1–4 kg) • FDA Warning: Increased CV mortality with tolbutamide (older agent); glimepiride shown CV-safe • Bone fractures: ADA 2026 flags SUs and TZDs — avoid in elevated fracture risk • Reduce dose when adding insulin or GLP-1 RA (hypoglycemia risk)" FULL-WIDTH DARK NAVY FOOTER: "ADA 2026 POSITION: DPP-4 inhibitors, sulfonylureas, and pioglitazone are second-line / adjunctive agents. When GLP-1 RA or SGLT2-i are started, ADA 2026 recommends limiting or discontinuing DPP-4i and sulfonylureas (no additional CV/kidney/weight/liver benefit). Pioglitazone may be retained for MASH benefit or insulin-sparing. In CKD: linagliptin (no dose adjustment), glipizide or glimepiride preferred over glyburide." White background, color-coded (green=start, red=contraindication, yellow=caution/decision, orange=adverse/hold, blue=dosing, teal=indications, purple=monitoring, navy=footer). All text clearly readable. Very tall poster accommodating all three complete flowchart sections.

ADA 2026 insulin therapy dosage titration basal bolus types indication contraindication table 9.2 section 9

ADA 2026 insulin initiation basal insulin starting dose titration algorithm T2DM eGFR renal adjustment

http://saigaiin.sakura.ne.jp/sblo_files/saigaiin/image/DM20E…

A very large tall professional medical reference poster on white background titled "INSULIN THERAPY — ADA 2026 Clinical Flowchart". Multiple clearly color-coded sections with bold headings, clear arrows, readable text. Professional clinical style. TITLE (very large, dark blue bold, centered at top): "INSULIN THERAPY — ADA 2026 Clinical Flowchart" Subtitle: "(Human Insulin & Analogs — SQ; Regular also available inhaled)" ═══ TOP: INSULIN TYPES REFERENCE TABLE ═══ DARK NAVY HEADER BOX: "INSULIN TYPES & PHARMACOKINETICS" Four columns side by side: COLUMN 1 — BASAL INSULINS (Long/Intermediate-Acting) — DARK BLUE header: "LONG-ACTING ANALOGS (Preferred): • Insulin Glargine U-100 (Lantus): Onset 2-4h | Peak: Peakless | Duration: ~24h • Insulin Glargine U-300 (Toujeo): Onset 6h | Peak: Peakless | Duration: >24h • Insulin Detemir (Levemir): Onset 1-2h | Peak: Minimal | Duration: 16-24h • Insulin Degludec U-100/U-200 (Tresiba): Onset 1h | Peak: Peakless | Duration: >42h INTERMEDIATE-ACTING (Human): • NPH (Humulin N / Novolin N): Onset 2-4h | Peak: 4-10h | Duration: 10-18h" COLUMN 2 — PRANDIAL / BOLUS INSULINS (Short/Rapid-Acting) — TEAL header: "RAPID-ACTING ANALOGS (Preferred): • Insulin Lispro (Humalog): Onset 15-30min | Peak: 30-90min | Duration: 3-5h • Insulin Aspart (NovoLog): Onset 10-20min | Peak: 40-50min | Duration: 3-5h • Insulin Glulisine (Apidra): Onset 10-15min | Peak: 30-90min | Duration: 3-5h • Ultra-Rapid: Faster Aspart (Fiasp), Lispro-aabc (Lyumjev): Onset <5min SHORT-ACTING (Human): • Regular insulin (Humulin R / Novolin R): Onset 30-60min | Peak: 2-4h | Duration: 5-8h Also available as INHALED (Afrezza): Onset 12-15min | Peak: 30min | Duration: 2-3h" COLUMN 3 — PREMIXED INSULINS — PURPLE header: "PREMIXED (Human & Analog): • NPH/Regular 70/30: 70% NPH + 30% Regular • Lispro 75/25 (Humalog Mix): 75% protamine + 25% lispro • Aspart 70/30 (NovoLog Mix): 70% protamine + 30% aspart • Use: Twice daily with meals (fixed ratio) • Limitation: Less flexibility; Higher hypoglycemia risk vs analogs" COLUMN 4 — CONCENTRATED INSULINS — ORANGE header: "CONCENTRATED: • Regular U-500 (Humulin R U-500): Severe insulin resistance; 5x concentration • Glargine U-300 (Toujeo): 3x concentration; longer duration • Degludec U-200 (Tresiba): 2x concentration Refer to device-specific instructions for pumps, connected pens, insulin patches (ADA 2026)" ═══ SECTION 2: INITIATION FLOWCHART ═══ GREEN BOX: "INDICATION TO START INSULIN" Split into two paths: LEFT PATH — TYPE 1 DIABETES: "T1DM — Insulin is MANDATORY (not optional) • Newly diagnosed T1DM: 0.2–0.6 units/kg/day total daily dose (TDD) • Divide: ~50% as BASAL + ~50% as PRANDIAL (at meals) • Honeymoon phase: lower doses may suffice • AID (Automated Insulin Delivery) systems: offer to ALL adults with T1DM (ADA 2026)" RIGHT PATH — TYPE 2 DIABETES: "T2DM — Consider insulin when: • A1C >10% OR blood glucose ≥300 mg/dL with symptoms • Failure of 2-3 oral/injectable agents • Symptomatic hyperglycemia • Pregnancy with inadequate glycemic control • Cancer treatment, surgery, critical illness, steroids" Both paths merge → YELLOW DIAMOND: "Which Insulin Regimen?" Four regimen paths: PATH A — GREEN: "BASAL INSULIN ALONE (Start here for most T2DM) Start: 10 units/day OR 0.1–0.2 units/kg/day SC at bedtime or same time each day Titrate: Increase by 2 units every 3 days until fasting glucose reaches target (80–130 mg/dL) OR increase 10–15% every 3 days Preferred agents: Glargine U-100, Detemir, Degludec (analogs preferred over NPH) Continue oral agents (especially metformin, SGLT2-i, GLP-1 RA) Stop: Sulfonylureas, meglitinides, DPP-4i when adding insulin" PATH B — TEAL: "BASAL + PRANDIAL (Basal-Bolus) — For T1DM or T2DM needing intensification Prandial initiation: Add 4 units/day OR 10% of basal dose with largest meal Titrate: Increase by 1–2 units or 10–15% every 3 days to reach PPG target (<180 mg/dL) Reduce basal by 4 units/day or 10% when adding prandial Stepwise: Add 1 prandial dose → 2 → 3 (full basal-bolus) T1DM TDD: 0.4–0.7 units/kg/day (higher in insulin resistance)" PATH C — PURPLE: "PREMIXED TWICE DAILY — Alternative for some T2DM Start: Unit-for-unit conversion from basal at same TDD 2/3 dose before breakfast | 1/3 dose before dinner Titrate: Adjust each component based on fasting and PPG Limitation: Less flexible; higher hypoglycemia risk" PATH D — ORANGE: "SELF-MIXED / SPLIT (NPH + Short/Rapid) 2/3 before breakfast | 1/3 before dinner Add 4 units or 10% of NPH dose as short/rapid with each injection Titrate each component individually" ═══ SECTION 3: TITRATION & MONITORING ═══ BLUE BOX: "TITRATION PRINCIPLES (ADA 2026) • Uptitrate or downtitrate at EVERY VISIT based on: A1C, CGM data, SMBG (fasting & postprandial) • Assess insulin dose adequacy and insulin-taking behaviors at every visit • Hypoglycemia: Determine cause; if no clear reason → lower dose by 10–20% • Overbasalization warning signs: bedtime-to-morning glucose differential ≥50 mg/dL, hypoglycemia (aware or unaware), high glucose variability • If overbasalized: consider adding prandial insulin rather than increasing basal further • CGM: Recommended for ALL patients on insulin (ADA 2026) — offer at diabetes onset and at any time • AID systems: Offer to ALL adults with T2DM on insulin (NEW ADA 2026)" ═══ SECTION 4: RENAL CONSIDERATIONS ═══ YELLOW/ORANGE BOX: "RENAL / KIDNEY DOSING (ADA 2026) • Lower insulin doses required as eGFR decreases • Titrate per clinical response — no fixed dose reduction formula • Risk of hypoglycemia INCREASES with severity of CKD (reduced insulin clearance) • Analogs preferred over human insulin (NPH/premixed) — lower hypoglycemia risk • Monitor glucose more frequently in CKD • Prefer analogs: glargine, detemir, degludec over NPH in renal impairment" ═══ SECTION 5: CONTRAINDICATIONS & CAUTIONS ═══ RED BOX: "CONTRAINDICATIONS / CAUTIONS • Hypoglycemia unawareness — use CGM/AID; reduce dose; use analogs • Insulin allergy (rare) — may require desensitization or switch formulation • Severe lipohypertrophy at injection sites — rotate sites • Do NOT use U-500 concentrated insulin in standard insulin syringes (dosing error risk) • Inhaled insulin (Afrezza): contraindicated in asthma, COPD, active lung disease • Premixed insulins: avoid in patients requiring flexible dosing (illness, variable meals)" ═══ SECTION 6: INDICATIONS SUMMARY ═══ TEAL BOX: "INDICATIONS (ADA 2026) TYPE 1 DIABETES: Absolute requirement — all patients TYPE 2 DIABETES: • Failure to meet glycemic targets on oral/injectable agents • A1C >10% or BG ≥300 mg/dL with symptoms • Gestational diabetes / pregnancy with inadequate control • Hospitalization, surgery, critical illness • Cancer therapy-induced severe hyperglycemia (Rec 9.33–9.36) • Immunotherapy-associated diabetes (assess for insulin need — NEW ADA 2026 Rec 9.33) • Continue metformin + SGLT2-i + GLP-1 RA when starting insulin (ADA 2026 Rec 9.23)" ═══ SECTION 7: ADVERSE EFFECTS ═══ PURPLE BOX: "ADVERSE EFFECTS TO MONITOR • Hypoglycemia — most significant; higher with human insulin (NPH/premixed) vs analogs; higher in CKD • Weight gain — significant; mitigate with GLP-1 RA combination • Injection site reactions — lipohypertrophy, lipoatrophy; rotate sites • Edema — early insulin therapy • Vision changes — transient with rapid glucose correction • Duration: Lifelong in T1DM; long-term / indefinite in T2DM as needed" DARK NAVY FOOTER: "ADA 2026 KEY POINTS: (1) Analogs preferred over human insulin — less hypoglycemia risk. (2) Continue metformin, SGLT2-i, GLP-1 RA when initiating insulin. (3) Stop sulfonylureas, meglitinides, DPP-4i. (4) Offer AID systems to ALL adults with T1DM and T2DM on insulin. (5) CGM recommended at diabetes onset for all on insulin. (6) Reassess insulin doses when adding/escalating GLP-1 RA or dual GIP/GLP-1 RA." White background, professional medical poster, color-coded sections clearly separated, bold headers, all text clearly readable, large enough to show all detail. Very tall image.

A very wide horizontal landscape medical reference flowchart poster on white background titled "INSULIN THERAPY — ADA 2026 Clinical Flowchart". Flow goes LEFT to RIGHT across the full width. Color-coded boxes, clear horizontal arrows, bold readable text, professional clinical style. TITLE (large dark blue bold, top center): "INSULIN THERAPY — ADA 2026 Clinical Flowchart" Subtitle (smaller): "Human Insulin & Analogs — SQ | Regular also available Inhaled (Afrezza)" ══════════════════════════════════════════════════════════ TOP ROW — INSULIN TYPES REFERENCE BAR (spans full width) ══════════════════════════════════════════════════════════ Five side-by-side colored boxes across the top: BOX 1 — DARK BLUE: "BASAL — Long-Acting Analogs (PREFERRED) • Glargine U-100 (Lantus): ~24h, peakless, once daily • Glargine U-300 (Toujeo): >24h, peakless, once daily • Detemir (Levemir): 16-24h, once or twice daily • Degludec (Tresiba): >42h, peakless, once daily" BOX 2 — STEEL BLUE: "BASAL — Intermediate (Human) • NPH (Humulin N): Onset 2-4h | Peak 4-10h | Duration 10-18h • 1-2x daily • Higher hypoglycemia risk vs analogs" BOX 3 — TEAL: "PRANDIAL — Rapid-Acting Analogs (PREFERRED) • Lispro (Humalog): onset 15-30 min • Aspart (NovoLog): onset 10-20 min • Glulisine (Apidra): onset 10-15 min • Faster Aspart (Fiasp) / Lispro-aabc (Lyumjev): <5 min • Duration 3-5h | Given before each meal" BOX 4 — GREEN: "PRANDIAL — Short-Acting (Human) • Regular (Humulin R / Novolin R) • Onset 30-60 min | Peak 2-4h | Duration 5-8h • Give 30 min BEFORE meals • Also available INHALED (Afrezza): onset 12-15 min" BOX 5 — PURPLE: "PREMIXED & CONCENTRATED • NPH/Regular 70/30 — twice daily with meals • Lispro 75/25, Aspart 70/30 — twice daily • U-500 Regular: severe insulin resistance only • Glargine U-300, Degludec U-200: concentrated basal • Use device-specific instructions (pumps, pens, patches)" ══════════════════════════════════════════════════════════ MAIN FLOWCHART — LEFT TO RIGHT HORIZONTAL FLOW ══════════════════════════════════════════════════════════ STEP 1 — GREEN START BOX (far left): "INDICATION FOR INSULIN T1DM: Mandatory — all patients T2DM: Consider when: • A1C >10% or BG ≥300 mg/dL + symptoms • Failure of oral/injectable agents • Pregnancy / GDM uncontrolled • Surgery, critical illness, hospitalization • Immunotherapy diabetes (NEW Rec 9.33) • Cancer drug hyperglycemia (Rec 9.33-9.36)" → RIGHT ARROW → STEP 2 — YELLOW DIAMOND: "T1DM or T2DM?" → T1DM arrow UP-RIGHT → BLUE BOX: "T1DM DOSING TDD: 0.2–0.6 units/kg/day 50% BASAL + 50% PRANDIAL Maintenance: 0.4–0.7 units/kg/day AID systems: Offer to ALL T1DM adults (ADA 2026) CGM: Recommended at diagnosis" → T2DM arrow DOWN-RIGHT → ORANGE BOX: "T2DM — START BASAL INSULIN Start: 10 units/day OR 0.1–0.2 units/kg/day SC Timing: Bedtime or same time daily Preferred: Glargine, Detemir, Degludec (analogs) Continue: Metformin + SGLT2-i + GLP-1 RA STOP: Sulfonylureas, Meglitinides, DPP-4i" → RIGHT ARROW (from both paths) → STEP 3 — BLUE BOX: "BASAL TITRATION ALGORITHM Increase by 2 units every 3 days OR 10–15% every 3 days Target FPG: 80–130 mg/dL Assess at EVERY visit: • CGM data / SMBG readings • Hypoglycemia episodes • Insulin-taking behaviors ↓ Hypoglycemia: Reduce 10–20%" → RIGHT ARROW → STEP 4 — YELLOW DIAMOND: "Basal Adequate? FPG at target but A1C still high / PPG elevated?" → YES (still above target) → TEAL BOX: "ADD PRANDIAL INSULIN Start: 4 units/day OR 10% of basal dose Give with LARGEST meal first Reduce basal by 4 units or 10% simultaneously Titrate: +1–2 units or 10–15% every 3 days PPG target: <180 mg/dL Step up: 1 meal → 2 meals → Full Basal-Bolus (3 meals) Preferred: Rapid-acting analogs over Regular" → RIGHT ARROW → STEP 5 — DARK BLUE BOX: "FULL BASAL-BOLUS or AID T1DM: Full MDI (Multiple Daily Injections) or AID T2DM: Basal-bolus if targets not met AID (Automated Insulin Delivery): Offer to ALL T1DM adults Offer to ALL T2DM adults on insulin (NEW ADA 2026) Reassess doses when adding/escalating GLP-1 RA or tirzepatide" → RIGHT ARROW → STEP 6 — PURPLE BOX: "ONGOING MONITORING & TITRATION Uptitrate OR downtitrate at every visit OVERBASALIZATION — Check if: • Bedtime-to-morning glucose ≥50 mg/dL • Hypoglycemia (aware or unaware) • High glucose variability Action: Add prandial rather than ↑ basal further CGM: All patients on insulin (Rec 9.25) Assess need for AID, pump, connected pen" ══════════════════════════════════════════════════════════ BOTTOM ROW — Three boxes spanning full width ══════════════════════════════════════════════════════════ BOTTOM LEFT — RED BOX: "CONTRAINDICATIONS / CAUTIONS • Inhaled insulin (Afrezza): contraindicated in asthma, COPD, active lung disease • U-500: do NOT use standard syringes — dedicated device only • Premixed: avoid when flexible dosing needed (illness, variable meals) • Allergy to insulin: rare — switch formulation • Lipohypertrophy: rotate injection sites — impairs absorption" BOTTOM MIDDLE — ORANGE BOX: "RENAL CONSIDERATIONS (ADA 2026) • Lower insulin doses required as eGFR decreases • Titrate per clinical response — no fixed formula • Hypoglycemia risk INCREASES with CKD severity • Analogs preferred over NPH/premixed in CKD • Monitor glucose more frequently in CKD • Insulin remains safe at any eGFR level (unlike other agents)" BOTTOM RIGHT — DARK NAVY BOX: "ADA 2026 KEY RULES 1. Continue metformin + SGLT2-i + GLP-1 RA when starting insulin (Rec 9.23) 2. STOP sulfonylureas, meglitinides, DPP-4i with insulin 3. Analogs PREFERRED over human insulin (less hypoglycemia) 4. Offer AID to ALL adults with T1DM and T2DM on insulin (NEW 2026) 5. CGM at diagnosis for all on insulin (Rec 9.25) 6. Reassess insulin doses when GLP-1 RA added/escalated 7. Duration: Lifelong T1DM | Long-term T2DM as needed ADVERSE EFFECTS: Hypoglycemia • Weight gain • Injection site reactions • Edema (early)" Wide landscape orientation, white background, left-to-right flow with clear horizontal arrows between steps, color-coded boxes, bold section titles, all text readable. Make it very wide to accommodate the horizontal layout.