1) Confirm diagnosis and classify diabetes

• A1c >= 6.5%
• Fasting plasma glucose >= 126 mg/dL (7.0 mmol/L)
• 2-hour OGTT glucose >= 200 mg/dL (11.1 mmol/L)
• Random glucose >= 200 mg/dL with classic symptoms

• Type 1/LADA clues: lean, ketosis, rapid weight loss, younger age, autoimmune history
• Type 2 clues: insulin resistance phenotype, gradual onset, metabolic syndrome
  If uncertain, consider C-peptide and diabetes autoantibodies.

2) Initial assessment at first visit

• Symptoms: polyuria, polydipsia, weight loss, blurry vision, infections
• Check for emergency features: DKA/HHS, dehydration, altered mental status
• History: duration of symptoms, meds (including steroids), family history, CVD/CKD/HF, smoking, alcohol
• Exam:
  • BP, BMI, waist, hydration
  • Foot exam (pulses, sensation, skin integrity)
  • Cardiovascular and neurologic screening
• Baseline labs:
  • A1c
  • CMP (renal/liver function, electrolytes)
  • Fasting lipid profile
  • Urine albumin-creatinine ratio + eGFR
  • Consider TSH, B12 baseline if long-term metformin expected
  • If type 1 concern: ketones, autoantibodies, C-peptide

3) Set individualized treatment targets early

• A1c <7% for many non-pregnant adults
• Fasting glucose ~80 to 130 mg/dL
• 2-hour postprandial <180 mg/dL
  Adjust for frailty, hypoglycemia risk, comorbidity, and life expectancy.

4) Start lifestyle treatment for everyone

• Medical nutrition therapy (reduce refined carbs, portion control, calorie deficit if overweight)
• Physical activity: >=150 min/week moderate aerobic + resistance 2 to 3 times/week
• Weight management target (often 5 to 10% loss)
• Sleep, stress, tobacco cessation, alcohol moderation
• Diabetes self-management education at diagnosis

5) Start glucose-lowering medication

1. Severe hyperglycemia/catabolic symptoms (e.g., A1c >=10%, glucose >=300, weight loss, ketonuria):
   consider initial insulin.
2. Otherwise, if no cardiorenal priority and mild-moderate elevation:
   metformin is common first-line (if eGFR allows).
3. If ASCVD, HF, or CKD present/high risk:
   prioritize GLP-1 RA and/or SGLT2 inhibitor with proven benefit, often independent of baseline A1c, then add metformin as needed.
4. Reassess every ~3 months and intensify promptly if not at target.

6) Cardiovascular and renal risk reduction (same day plan)

• BP control and antihypertensive therapy as indicated (ACEi/ARB especially with albuminuria)
• Statin therapy based on age/risk profile
• Antiplatelet therapy only when indicated
• Vaccinations: influenza, pneumococcal, hepatitis B, COVID per local guidance
• Renal protection strategy if albuminuria/CKD

7) Screen for complications at baseline

• Eyes: dilated retinal exam
• Kidneys: UACR + eGFR
• Neuropathy/feet: monofilament + foot risk exam
• ASCVD risk: lipids, BP, smoking status
• Dental and periodontal health, depression screening, sleep apnea risk if appropriate

8) Follow-up cadence

• 2 to 6 weeks initially if medication changes or high glucose burden
• A1c every 3 months until controlled, then every 6 months
• Review SMBG/CGM data, hypoglycemia episodes, adherence, side effects, affordability
• Escalate treatment quickly if above target

9) Patient education and safety checklist

• Hypoglycemia recognition and treatment
• Sick-day rules
• Foot care and when to seek urgent care
• Home glucose monitoring plan
• Shared decision-making around cost, route (oral/injectable), and weight goals

Source notes used

• ADA Standards of Care framework emphasizes individualized care and evidence-based updates (Diabetes Standards of Care 2025, p.2).
• Cardiorenal-focused pharmacotherapy supports early GLP-1 RA/SGLT2 use in T2D with ASCVD/CKD/HF risk (Management of Cardiovascular Disease in Patients with Diabetes, p.29).