How to Explain This Slide to Your Class

What This Slide Is

How to Start Your Presentation (Opening Statement)

"Type 2 diabetes is not treated the same way in every patient. The choice of medication depends on what problems the patient ALSO has - like heart disease, kidney disease, obesity, or heart failure. This ADA algorithm guides that choice systematically."

The Big Picture - Three Pillars

Healthy lifestyle behaviors + Diabetes self-management education + Social determinants of health

The Two Main Branches

LEFT SIDE - Explained Step by Step

1. +ASCVD (Atherosclerotic Cardiovascular Disease)

• Patient has had a heart attack, stroke, or confirmed artery disease
• Choose GLP-1 RA with proven CVD benefit (e.g., semaglutide/dulaglutide) OR SGLT2i with proven CVD benefit (e.g., empagliflozin/canagliflozin)
• If blood sugar is still above goal → add the other class (GLP-1 + SGLT2i combination), or consider pioglitazone (⚠ caution: risk of heart failure, bone loss, bladder cancer)

2. +Indicators of High CVD Risk (but no established ASCVD yet)

• Same recommendation: GLP-1 RA or SGLT2i

3. +HF (Heart Failure)

• SGLT2 inhibitors are the drug of choice - they have proven heart failure benefit (both HFrEF and HFpEF)
• Can combine with GLP-1 RA if needed, especially in obese patients with heart failure
• Key fact: SGLT2i are the only diabetes drugs with a direct heart failure benefit

4. +CKD (Chronic Kidney Disease)

• Defined as: eGFR < 60 mL/min/1.73 m² OR albuminuria (ACR ≥ 3.0 mg/mmol)
• On maximally tolerated ACEi or ARB (these protect the kidneys)
• First choice: SGLT2i - they reduce CKD progression
  • Can start if eGFR ≥ 20 mL/min/1.73 m²
  • Glucose-lowering effect is reduced when eGFR < 45
• If SGLT2i not tolerated: GLP-1 RA with proven CKD benefit (semaglutide)
• If sugar still high: add GLP-1 RA to SGLT2i or vice versa

RIGHT SIDE - Explained Step by Step

5. +Weight Management

6. +Achievement and Maintenance of Glycemic Goals

BOTTOM SECTION

MASLD / MASH (Liver Disease)

• MASLD = Metabolic dysfunction-associated steatotic liver disease (fatty liver)
• MASH = the inflammatory form with scarring
• Preferred agents: GLP-1 RA, dual GIP/GLP-1 RA (tirzepatide), pioglitazone, or their combinations
• If the patient has decompensated cirrhosis (liver failure): use insulin - it is the only safe option

Bottom Teal Bar - When to Escalate

"If glycemia is above goal OR significant hypoglycemia OR hyperglycemia OR barriers to care are identified..."

• Refer to DSMES (Diabetes Self-Management Education and Support)
• Consider CGM (Continuous Glucose Monitor) to find patterns
• Address SDOH - social/economic barriers

Key Abbreviations You MUST Know

Possible Teacher/Examiner Questions (With Answers)

Conceptual Questions

Because the algorithm is now complication-driven. If a patient has CVD, CKD, or HF, specific drugs (GLP-1 RA or SGLT2i) take priority regardless of glucose levels. Metformin is still used for glycemic goals but is no longer the universal starting point.

SGLT2i reduce sodium reabsorption in the kidney, which decreases preload and afterload. They also have diuretic effects and reduce cardiac inflammation/oxidative stress. Clinical trials (EMPEROR-Reduced, DAPA-HF) showed benefit in BOTH HFrEF and HFpEF - hence the slide recommends them for all HF types.

Both enhance GLP-1 activity, but in different ways. DPP-4i block the enzyme that breaks down endogenous GLP-1, producing modest increases. GLP-1 RA are synthetic analogs that directly activate GLP-1 receptors at much higher concentrations. Result: GLP-1 RA cause significantly more weight loss and glucose lowering, plus proven CVD benefits. DPP-4i are weight-neutral with intermediate glucose efficacy. The slide even says: do NOT combine DPP-4i with GLP-1 RA (they act on the same pathway - redundant).

SGLT2i lower glucose by blocking glucose reabsorption in the proximal tubule. This requires adequate filtered glucose load - which decreases as kidney function falls. Below eGFR 45, not enough glucose reaches the tubule. However, the kidney-protective effects (reducing intraglomerular pressure, reducing albuminuria) are independent of this glucose mechanism, which is why they are still used for CKD even at low eGFR.

Tirzepatide is a dual GIP + GLP-1 agonist - the dual mechanism gives superior weight loss (~20%). But the CKD-specific trials (FLOW trial) used semaglutide specifically, so that is the one with proven CKD data. Evidence is trial-specific.

Therapeutic inertia is the failure to advance treatment when targets are not met. Many physicians keep patients on ineffective regimens for years. The slide explicitly says: reassess every 3-6 months and modify treatment. Inertia leads to preventable complications.

SGLT2i (e.g., empagliflozin or dapagliflozin). It has proven benefit in both HF and CKD. It can be started at eGFR ≥ 20. The glucose-lowering will be reduced, but the organ-protective benefit is maintained. Add GLP-1 RA if glycemia remains above goal.

The slide specifically mentions insulin in two situations: (1) as a combination therapy with GLP-1 RA for very high glucose efficacy in the right-side branch, and (2) when the patient has decompensated cirrhosis (MASLD/MASH section) - because it is the only safe option when the liver cannot metabolize oral drugs reliably.

Pioglitazone causes fluid retention (risk of heart failure), bone loss (increased fracture risk), and bladder cancer. Use with caution. It is still listed because it is insulin-sensitizing and beneficial in fatty liver disease (MASLD/MASH), but these risks must be weighed.

Diabetes Self-Management Education and Support helps patients understand their condition, manage medications, check blood sugar, make dietary changes, and address psychological barriers. It improves glycemic control and reduces complications independently of medication.

Application/Case Questions

GLP-1 RA with proven CVD benefit (e.g., semaglutide) or SGLT2i with proven CVD benefit (e.g., empagliflozin) - left branch of the algorithm, ASCVD pathway.

Tirzepatide (Very High efficacy for weight loss) or semaglutide (also Very High).

Tips for Your Presentation

1. Start from the top: foundation box first, then split into two columns
2. Use a pointer/cursor to trace each pathway as you explain it
3. Give one real drug name per category so it sounds clinical (e.g., "SGLT2i like empagliflozin")
4. Abbreviation key: quickly define each abbreviation the first time you say it
5. End with the MASLD section and the bottom escalation bars - they are easy to forget but teachers notice
6. The footnotes at the bottom are exam gold - pioglitazone warning, GLP-1 RA definition, SGLT2i definition - read them aloud

THE SLIDE IN SIMPLE WORDS

What is this slide about?

In Type 2 Diabetes, you don't give the same drug to every patient. You choose the drug based on what OTHER problems the patient has.

FOUNDATION (Top Box)

• Healthy diet + exercise
• Patient education
• Address social issues (poverty, food access)
• Reassess every 3-6 months - don't leave a patient on a failing treatment

LEFT SIDE - Patient has complications (Heart/Kidney)

RIGHT SIDE - Patient needs weight/sugar control

• 🥇 Very High: Semaglutide, Tirzepatide
• 🥈 High: Dulaglutide, Liraglutide
• 🥉 Intermediate: SGLT2i, other GLP-1 RA
• Neutral (no weight change): Metformin, DPP-4i

• 🥇 Very High: Tirzepatide, Semaglutide, Insulin, GLP-1+Insulin combo
• 🥈 High: Metformin, Sulfonylurea, SGLT2i, Pioglitazone
• 🥉 Intermediate: DPP-4i

BOTTOM - Fatty Liver (MASLD/MASH)

• Use: GLP-1 RA, Tirzepatide, Pioglitazone
• If liver is failing (cirrhosis): Insulin only

KEY DRUG NAMES TO KNOW

TOP 10 TEACHER QUESTIONS + QUICK ANSWERS

"The key message of this slide is: treat the whole patient, not just the blood sugar. Choose the drug that protects the organ most at risk."