Type 2 diabetes
Confirm diagnosis, baseline assessment, and first-line management priorities.
Last reviewed January 5, 2026
Red flags
- Marked hyperglycemia with dehydration, ketones, or significant weight loss.
- Recurrent severe hypoglycemia or inability to safely self-manage.
Diagnosis
- Confirm with A1C, fasting plasma glucose, or a random plasma glucose with symptoms.
- Clarify diabetes type and duration; assess for acute hyperglycemia symptoms.
Initial workup
- Baseline A1C, lipids, creatinine/eGFR, urine ACR, blood pressure, and BMI.
- Foot exam and neuropathy screening; arrange retinal screening if not up to date.
- Review cardiovascular risk, sleep, mental health, and vaccination status.
First-line management
- Lifestyle coaching: nutrition, activity, weight, and smoking cessation.
- Start metformin if tolerated and eGFR allows; escalate therapy based on comorbidities.
- For heart failure or CKD, assess eligibility for an SGLT2 inhibitor with proven benefit. For ASCVD or high cardiovascular risk, choose an SGLT2 inhibitor or GLP-1 RA with demonstrated benefit for that indication; these classes are not interchangeable for every outcome.
Referral triggers
- Unclear diabetes type, pregnancy, or suspected secondary causes.
- Advanced CKD, complex insulin management, or persistent A1C above target despite therapy.
References
- Diabetes Canada 2024 pharmacologic management update (opens in a new tab)
- Diabetes Canada 2025 CKD in diabetes guideline (opens in a new tab)
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