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endo.dm2.core.v1PRODUCTION
endo.dm2.core.v1

Type 2 diabetes (chronic outpatient)

endocrinologychronicadult
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Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Chronic outpatient T2DM scope per ADA 2026 §2 — exclude DKA/HHS (route to acute engines) and confirm not T1DM (autoantibodies if suspected)

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Actions
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Advance rule
Set
Advance when

chronic T2DM scope confirmed per ADA 2026 diagnostic criteria

Patient inputs (13)

Age modulates A1c target (frailty, life expectancy) and CV risk per ADA 2026 Table 6.2

BMI gates GLP-1/dual agonist + bariatric referral; weight target per ADA 2026 §8

BP target <130/80 in T2D per 2025 ACC/AHA HTN guideline

Established ASCVD → GLP-1 RA or SGLT2i with proven CV benefit per ADA 2026 §10 + EASD/ADA 2022 consensus

HF (HFrEF or HFpEF) → SGLT2i mandatory regardless of A1c per EMPEROR-Reduced (Packer NEJM 2020) + DAPA-HF (McMurray NEJM 2019)

CKD → SGLT2i + finerenone + ACEi/ARB optimization per KDIGO 2024 + CREDENCE (Perkovic NEJM 2019) + FIDELIO-DKD (Bakris NEJM 2020)

Diagnostic (≥6.5%), target-tracking, regimen escalation trigger per ADA 2026 §2

eGFR gates SGLT2i (≥20), metformin (≥30), dose adjustments per KDIGO 2024 + ADA 2026 §11

UACR ≥30 → finerenone + RAAS optimization (KDIGO 2024)

Biopsy-proven MASH → GLP-1 RA preferred (ADA 2026)

Detect existing GDMT; flag steroids, atypical antipsychotics, beta-blockers (hypoglycemia masking) per ADA 2026 §4

Statin candidacy + CV risk; 2026 ACC/AHA dyslipidemia targets

Metformin → B12 deficiency; check after 4 yr or with neuropathy per ADA 2026 §9

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (10)

10 need judgement
  • informationalseverea1c_gt_10_severe_hyperglycemia
    A1c >10% OR fasting BG >250 with symptoms per ADA 2026 §9
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresevere_hypoglycemia_unawareness
    ≥1 severe hypo event OR hypoglycemia unawareness reported per ADA 2026 §6
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepregnancy_planning_T2DM
    T2DM patient planning pregnancy or pregnant per ADA 2026 §15
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereeuglycemic_dka_risk_on_sglt2i
    T2DM patient on SGLT2i with intercurrent illness, surgery within 72h, ketogenic/low-carb diet, prolonged fasting, alcohol binge, or insulin reduction — at risk of euglycemic DKA (glucose <250 with AGMA + ketones) per ADA 2026 §9 + FDA 2015 SGLT2i class warning
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveretirzepatide_or_glp1_pancreatitis_risk
    GLP-1 RA or tirzepatide on board with new severe abdominal pain, persistent vomiting, elevated lipase ≥3x ULN per ADA 2026 §9 class label warning
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateascvd_present_no_proven_agent
    Established ASCVD without GLP-1 RA or SGLT2i with proven CV benefit per ADA 2026 §10
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatehf_present_no_sglt2i
    Heart failure (any EF) without SGLT2i per ADA 2026 §10
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateegfr_lt_30_metformin
    eGFR <30 with metformin still on board per KDIGO 2024 + ADA 2026 §9
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateuacr_ge_300_no_finerenone
    UACR ≥300 + eGFR ≥25 + K ≤5.0 + on max RAAS without finerenone per KDIGO 2024
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatemash_advanced_fibrosis_no_glp1
    Biopsy-proven MASH with significant fibrosis (F2-F3) or imaging-confirmed MASH with FIB-4 >2.67, not on GLP-1 RA per ADA 2026 + AASLD 2023
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

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Recommended regimen

ADA 2026 §9 — comorbidity-first glycemic stepwise ladder (cardiorenal indications independent of A1c)
axis: dm2_glycemic_stepwisestep 1 - Step 1 — Lifestyle + metformin foundation per ADA 2026 §9
Selected step "Step 1 — Lifestyle + metformin foundation per ADA 2026 §9" — New T2DM with eGFR ≥30 and no SGLT2i/GLP-1-mandating comorbidity yet identified per ADA 2026 §9
  • metformin
    first line
    biguanide
    500 mg • PO • BID with meals; titrate to 1000 mg BID over 4 wk
    triggers: eGFR>=30, no_compelling_comorbidity
    ADA 2026 §9 foundation; A1c approx -1.0 to -1.5%, glycemic effect 1-2 wk. UKPDS 80 legacy: metformin MI -33% (p=0.005), all-cause death -27% (p=0.002) at 10 y post-trial (PMID 18784090). B12 q1-2y after 4 y.
    rxcui 6809

outpatient playbook — drug actions (8)

  1. 1. metformin
    500 mg PO BID, titrate to 1000 mg BID over 4 weeks per ADA 2026 §9 • PO • BID with meals
    trigger: New T2DM diagnosis with eGFR ≥30 per ADA 2026 §9
    ADA SoC 2026 — first-line foundation; cardiometabolic benefits beyond A1c per UKPDS (Lancet 1998)
  2. 2. SGLT2i (empagliflozin or dapagliflozin)
    Empagliflozin 10–25 mg PO daily; dapagliflozin 10 mg PO daily per ADA 2026 §9 • PO • once daily
    trigger: HF (any EF) OR CKD with UACR ≥200 OR ASCVD; eGFR ≥20 per ADA 2026 §10 + KDIGO 2024
    EMPEROR Packer NEJM 2020 + DAPA-HF McMurray NEJM 2019 + DAPA-CKD Heerspink NEJM 2020 + CREDENCE Perkovic NEJM 2019 — cardiorenal protection irrespective of A1c
  3. 3. GLP-1 RA (semaglutide / liraglutide / dulaglutide / tirzepatide) per ADA 2026 Table 9.1
    Semaglutide 0.25 mg SC weekly x 4 wk then 0.5–2 mg; tirzepatide 2.5 mg SC weekly then 5–15 mg per ADA 2026 §9 • SC • weekly
    trigger: ASCVD OR BMI ≥27 with cardiometabolic comorbidity OR MASH OR weight loss priority per ADA 2026 §10
    SUSTAIN-6 / LEADER / REWIND / SURPASS — CV + weight benefit; ADA 2026 prefers GLP-1 in MASH
  4. 4. finerenone
    10 mg PO daily (eGFR 25–60 with K ≤4.8); titrate to 20 mg if K ≤4.8 + eGFR stable per KDIGO 2024 • PO • once daily
    trigger: UACR ≥30 + eGFR ≥25 + K ≤5.0 on max RAAS per KDIGO 2024
    FIDELIO-DKD Bakris NEJM 2020 + FIGARO-DKD Pitt NEJM 2021 — cardiorenal benefit additive to RAAS + SGLT2i
  5. 5. basal insulin (glargine or degludec) per ADA 2026 §9
    Glargine 0.1–0.2 U/kg SC daily (typically 10 U start); titrate by 2 U q3 days to fasting target per ADA 2026 §9 • SC • once daily
    trigger: A1c >10% OR symptomatic hyperglycemia OR oral failure OR catabolic features per ADA 2026 §9
    ADA SoC 2026 — when A1c severely elevated, insulin start is appropriate; can de-escalate later if cardiorenal agents working
  6. 6. prandial insulin (lispro/aspart) per ADA 2026 §9
    4 U with largest meal, titrate by 1–2 U q3 days per ADA 2026 §9 • SC • with meals
    trigger: Postprandial hyperglycemia despite optimal basal per ADA 2026 §9
    Stepwise basal-plus → basal-bolus per ADA 2026 §9
  7. 7. statin per ADA 2026 §10
    Atorvastatin 40–80 mg or rosuvastatin 20–40 mg PO daily per 2026 ACC/AHA Lipid • PO • daily
    trigger: All T2DM age 40–75 (moderate-high intensity); add ezetimibe if LDL >70 with ASCVD per ADA 2026 §10
    2026 ACC/AHA Lipid
  8. 8. ACE-I or ARB per ADA 2026 §10 + KDIGO 2024
    Lisinopril 10–40 mg PO daily; losartan 50–100 mg PO daily per ADA 2026 §10 • PO • daily
    trigger: HTN OR UACR ≥30; titrate to max tolerated per KDIGO 2024
    CKD + CV benefit; first-line in T2DM with HTN/CKD per ADA + KDIGO

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: HbA1c ≥6.5% / elevated FPG / 2-h OGTT ≥200 (ADA 2026 §2 diagnostic criteria); Polyuria + polydipsia + weight loss per ADA 2026 §2; Established T2DM (titration / annual review per ADA 2026 §4).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Type 2 diabetes (chronic outpatient)** (endo.dm2.core.v1).
Phenotype framing: Phenotype per ADA 2026 Figure 9.3: newly-diagnosed uncomplicated, ASCVD, HF, CKD, obesity-cardiometabolic, MASH, pre-pregnancy planning, frail/end-of-life
Scope: Chronic outpatient T2DM scope per ADA 2026 §2 — exclude DKA/HHS (route to acute engines) and confirm not T1DM (autoantibodies if suspected)

No severity triggers fired against current inputs.

Plan

Regimen axis: **ADA 2026 §9 — comorbidity-first glycemic stepwise ladder (cardiorenal indications independent of A1c)** — step "Step 1 — Lifestyle + metformin foundation per ADA 2026 §9".
1. metformin 500 mg PO BID with meals; titrate to 1000 mg BID over 4 wk (biguanide, first line) — ADA 2026 §9 foundation; A1c approx -1.0 to -1.5%, glycemic effect 1-2 wk. UKPDS 80 legacy: metformin MI -33% (p=0.005), all-cause death -27% (p=0.002) at 10 y post-trial (PMID 18784090). B12 q1-2y after 4 y.

Setting playbook (outpatient) — Achieve individualized A1c target + cardiorenal protection + weight + complication screening per ADA SoC 2026
2. metformin 500 mg PO BID, titrate to 1000 mg BID over 4 weeks per ADA 2026 §9 PO BID with meals — New T2DM diagnosis with eGFR ≥30 per ADA 2026 §9 (ADA SoC 2026 — first-line foundation; cardiometabolic benefits beyond A1c per UKPDS (Lancet 1998))
3. SGLT2i (empagliflozin or dapagliflozin) Empagliflozin 10–25 mg PO daily; dapagliflozin 10 mg PO daily per ADA 2026 §9 PO once daily — HF (any EF) OR CKD with UACR ≥200 OR ASCVD; eGFR ≥20 per ADA 2026 §10 + KDIGO 2024 (EMPEROR Packer NEJM 2020 + DAPA-HF McMurray NEJM 2019 + DAPA-CKD Heerspink NEJM 2020 + CREDENCE Perkovic NEJM 2019 — cardiorenal protection irrespective of A1c)
4. GLP-1 RA (semaglutide / liraglutide / dulaglutide / tirzepatide) per ADA 2026 Table 9.1 Semaglutide 0.25 mg SC weekly x 4 wk then 0.5–2 mg; tirzepatide 2.5 mg SC weekly then 5–15 mg per ADA 2026 §9 SC weekly — ASCVD OR BMI ≥27 with cardiometabolic comorbidity OR MASH OR weight loss priority per ADA 2026 §10 (SUSTAIN-6 / LEADER / REWIND / SURPASS — CV + weight benefit; ADA 2026 prefers GLP-1 in MASH)
5. finerenone 10 mg PO daily (eGFR 25–60 with K ≤4.8); titrate to 20 mg if K ≤4.8 + eGFR stable per KDIGO 2024 PO once daily — UACR ≥30 + eGFR ≥25 + K ≤5.0 on max RAAS per KDIGO 2024 (FIDELIO-DKD Bakris NEJM 2020 + FIGARO-DKD Pitt NEJM 2021 — cardiorenal benefit additive to RAAS + SGLT2i)
6. basal insulin (glargine or degludec) per ADA 2026 §9 Glargine 0.1–0.2 U/kg SC daily (typically 10 U start); titrate by 2 U q3 days to fasting target per ADA 2026 §9 SC once daily — A1c >10% OR symptomatic hyperglycemia OR oral failure OR catabolic features per ADA 2026 §9 (ADA SoC 2026 — when A1c severely elevated, insulin start is appropriate; can de-escalate later if cardiorenal agents working)
7. prandial insulin (lispro/aspart) per ADA 2026 §9 4 U with largest meal, titrate by 1–2 U q3 days per ADA 2026 §9 SC with meals — Postprandial hyperglycemia despite optimal basal per ADA 2026 §9 (Stepwise basal-plus → basal-bolus per ADA 2026 §9)
8. statin per ADA 2026 §10 Atorvastatin 40–80 mg or rosuvastatin 20–40 mg PO daily per 2026 ACC/AHA Lipid PO daily — All T2DM age 40–75 (moderate-high intensity); add ezetimibe if LDL >70 with ASCVD per ADA 2026 §10 (2026 ACC/AHA Lipid)
9. ACE-I or ARB per ADA 2026 §10 + KDIGO 2024 Lisinopril 10–40 mg PO daily; losartan 50–100 mg PO daily per ADA 2026 §10 PO daily — HTN OR UACR ≥30; titrate to max tolerated per KDIGO 2024 (CKD + CV benefit; first-line in T2DM with HTN/CKD per ADA + KDIGO)

Non-pharmacologic actions:
- Medical nutrition therapy (RDN referral) per ADA 2026 §5
- DSME structured program at diagnosis + as needed per ADA 2026 §5
- Physical activity ≥150 min/week moderate aerobic + resistance training 2–3x/week per ADA 2026 §5
- Weight loss target 5–10% body weight per ADA 2026 §8
- CGM start per ADA 2026 §7 expanded coverage (insulin-treated T2DM)
- Smoking cessation pharmacotherapy if applicable per ADA 2026 §5
- Vaccinations (flu, pneumococcal PCV20 or PCV15+PPSV23, COVID, RSV ≥60, Tdap, HepB, zoster ≥50) per ADA 2026 §4
- Retinal screen annual; foot exam annual per ADA 2026 §12
- Mental health referral if depression/diabetes distress per ADA 2026 §5
- Sleep apnea screen if BMI ≥35 per ADA 2026 §4
- Bariatric/metabolic surgery referral if BMI ≥35 + DM per ADA 2026 §8

AVOID / contraindication checks:
- Metformin block if egfr lt 30 per KDIGO 2022 + ADA 2026 §9
- Sglt2i block if egfr lt 20 or active DKA per ADA 2026 §9 + FDA label
- Glp1 caution if gastroparesis or pancreatitis per ADA 2026 §9 class label
- Finerenone block if K gt 5.0 per FIDELIO DKD (PMID 33264825) + KDIGO 2022
- Su avoid low egfr glyburide block per ADA 2026 §9
- Tzd avoid in hf per ADA 2026 §9 + ACC/AHA HF guidelines
- Non insulin agents off in pregnancy per ADA 2026 §15

Monitoring

Regimen monitoring:
- A1c q3m until target then q6m per ADA 2026 §6
- BMP within 2w after SGLT2i or finerenone start per KDIGO 2022
- UACR + eGFR q3-6m if CKD per KDIGO 2022
- B12 q1-2y on metformin per ADA 2026 §9
- LFT q6m if MASH or TZD per ADA 2026 §4

Setting (outpatient) monitoring:
- A1c q3 mo until target then q6 mo per ADA 2026 §6
- BMP within 2 weeks of SGLT2i / finerenone start per KDIGO 2024
- UACR + eGFR q3–6 mo if CKD per KDIGO 2024
- B12 q1–2y on metformin per ADA 2026 §9
- LFT q6 mo if MASH or TZD per ADA 2026 §4
- CGM data review q visit per ADA 2026 §7
- Hypoglycemia frequency review per ADA 2026 §6

Follow-up plan: DSME, vaccinations (flu/pneumococcal/COVID/RSV/Tdap/HepB/zoster), psychosocial + fear-of-hypoglycemia + anxiety screen (ADA 2026), pre-pregnancy counseling
- Close-out criterion: follow-up scheduled per ADA 2026 §5; education + screening complete

Monitoring phase: A1c q3m until target then q6m per ADA 2026 §6; UACR + eGFR q3-6m if CKD per KDIGO 2024; BP each visit; weight quarterly; B12 q1-2y on metformin; retinal annually; foot annually per ADA 2026 §4

Disposition

Current setting: outpatient — Achieve individualized A1c target + cardiorenal protection + weight + complication screening per ADA SoC 2026

Disposition criteria:
- Q3 mo follow-up if uncontrolled or new agent per ADA 2026 §4
- Q6 mo if at target per ADA 2026 §6
- Endocrinology referral if A1c >9% x 6 mo despite triple therapy per ADA 2026 §9
- Nephrology referral if eGFR <30 or UACR >300 per KDIGO 2024
- Bariatric referral if BMI ≥35 with DM per ADA 2026 §8

Escalation triggers (move to higher acuity):
- A1c >10% OR symptomatic hyperglycemia → consider basal insulin start per ADA 2026 §9
- eGFR <30 → adjust metformin (max 500 mg BID), consider stop per KDIGO 2024; SGLT2i continue if already started for HF/CKD
- eGFR <20 → stop metformin + SGLT2i per KDIGO 2024
- New ASCVD → mandate GLP-1 or SGLT2i with proven CV benefit per ADA 2026 §10 + EASD/ADA 2022
- New HF (any EF) → mandate SGLT2i per ADA 2026 §10 + DAPA-HF (McMurray NEJM 2019)
- Severe hypoglycemia OR DKA pattern → DKA/HHS engine + endocrine consult per ADA 2026 §6
- Pregnancy planning → switch to insulin-only regimen + MFM per ADA 2026 §15 + ACOG

Patient Action Plan

**T2DM patient action plan — sick-day rules, hypoglycemia, hyperglycemia (ADA 2026)**
Personalised values: individualized_A1c_target, home_glucose_targets, insulin_regimen, cardiorenal_phenotype, hypoglycemia_unawareness_status.

**On track — at A1c + glucose target per ADA 2026 §6** (green):
Triggers:
- Fasting BG within personal target (often 80–130 mg/dL) per ADA 2026 §6
- Postprandial BG <180 mg/dL per ADA 2026 §6
- No hypoglycemic episodes per ADA 2026 §6
- No new symptoms (polyuria, polydipsia, weight loss) per ADA 2026 §2
- Adhering to medication + lifestyle plan per ADA 2026 §5
Actions:
- Continue all medications as prescribed per ADA 2026 §9 (do not skip if feeling well)
- Maintain MNT, activity, weight goals per ADA 2026 §5
- Keep scheduled labs + appointments per ADA 2026 §4
- Continue daily foot inspection + dental hygiene per ADA 2026 §12

**Caution — sick day OR mild hypo OR hyperglycemia trend per ADA 2026 §6** (yellow):
Triggers:
- Acute illness (fever, vomiting, diarrhea, infection) per ADA 2026 §6 sick-day rules
- Glucose 70–80 mg/dL (mild low) OR fasting >180 / postprandial >250 mg/dL per ADA 2026 §6
- Increased thirst, urination, fatigue per ADA 2026 §2
- New medication (steroid, antipsychotic) in last 1–2 weeks per ADA 2026 §4
- Weight loss without trying per ADA 2026 §2
Actions:
- SICK DAY RULES per ADA 2026 §6: Do NOT stop insulin (basal continues even if not eating; reduce prandial 50% if poor PO); HOLD SGLT2i during acute illness with poor PO (ketosis risk per FDA 2015 class warning); HOLD metformin if dehydrated/AKI risk; HOLD ACEi if dehydrated
- Monitor BG q2–4h while ill per ADA 2026 §6
- Check ketones (urine or blood BHB) if T1DM or on SGLT2i with BG >250 per ADA 2026 §6
- Hydrate aggressively per ADA 2026 §6 sick-day management
- For mild hypo (BG 54–70): 15 g fast carb (4 oz juice, 3–4 glucose tabs), recheck in 15 min, repeat if still <70 per ADA 2026 §6
- Increase BG checks to QID until back to baseline per ADA 2026 §6
- Contact provider if illness >24h, ketones moderate-large, BG >300 persistent, or vomiting per ADA 2026 §6
Contact provider when:
- Persistent hyperglycemia >300 mg/dL x 24h per ADA 2026 §6
- Moderate-large ketones per ADA 2026 §6
- Inability to keep PO down per ADA 2026 §6
- Severe hypoglycemia or hypoglycemia unawareness per ADA 2026 §6

**Emergency — DKA, HHS, severe hypoglycemia, foot infection, AMS per ADA 2026 §16** (red):
Triggers:
- Severe hypoglycemia (BG <54 OR requiring assistance OR LOC) per ADA 2026 §6
- BG >400 mg/dL with ketones / Kussmaul breathing / vomiting / abdominal pain per ADA 2026 §16
- AMS, confusion, seizure, coma per ADA 2026 §16
- Severe foot infection (red streaks, fever, deep ulcer with exposed bone) per ADA 2026 §12
- Chest pain or new neuro deficit per ADA 2026 §10
Actions:
- Severe hypo: caregiver gives IM glucagon 1 mg + call 911 per ADA 2026 §6
- Hyperglycemia + ketones / vomiting / AMS: call 911 + go to ED for DKA/HHS workup per ADA 2026 §16
- Severe foot infection: ED now per ADA 2026 §12
- Chest pain / stroke symptoms: 911 per ADA 2026 §10
- Bring all medications + insulin to hospital per ADA 2026 §16
Contact provider when:
- Any red zone trigger — go to ED, do not wait per ADA 2026 §16

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [SEVERE] A1c >10% OR fasting BG >250 with symptoms per ADA 2026 §9
- [SEVERE] ≥1 severe hypo event OR hypoglycemia unawareness reported per ADA 2026 §6
- [SEVERE] T2DM patient planning pregnancy or pregnant per ADA 2026 §15

Citations

- ADA Standards of Care 2026 + AACE 2023 + KDIGO 2024 Diabetes-CKD + EASD/ADA 2022 Hyperglycemia Consensus + 2026 ACC/AHA Lipid + 2025 AHA/ACC HTN + AASLD 2023 MASH (resmetirom 2024 FDA approval) [PMID:41358893](https://pubmed.ncbi.nlm.nih.gov/41358893/)
- Cited evidence (PMID 41358900) [PMID:41358900](https://pubmed.ncbi.nlm.nih.gov/41358900/)
- Cited evidence (PMID 36272764) [PMID:36272764](https://pubmed.ncbi.nlm.nih.gov/36272764/)
- Cited evidence (PMID 26378978) [PMID:26378978](https://pubmed.ncbi.nlm.nih.gov/26378978/)
- Cited evidence (PMID 30990260) [PMID:30990260](https://pubmed.ncbi.nlm.nih.gov/30990260/)

Last reconciled with current guidelines: 2026-05-22.
References
  • ADA Standards of Care 2026 + AACE 2023 + KDIGO 2024 Diabetes-CKD + EASD/ADA 2022 Hyperglycemia Consensus + 2026 ACC/AHA Lipid + 2025 AHA/ACC HTN + AASLD 2023 MASH (resmetirom 2024 FDA approval) — PMID:41358893
  • Cited evidence (PMID 41358900) — PMID:41358900
  • Cited evidence (PMID 36272764) — PMID:36272764
  • Cited evidence (PMID 26378978) — PMID:26378978
  • Cited evidence (PMID 30990260) — PMID:30990260