TYPE TWO DIABETES












Reference [2]
Age (years) U.S. prevalence
(% of total population)
20 - 44 4.1%
45 - 64 16.2%
≥ 65 25.9%




  • Incidence ratio = incidence with affected family members/incidence with no affected family members
  • Reference [4]
Relative with T2DM Incidence ratio
One parent 2.0
Two parents 5.3
One sibling 2.8
Two siblings 37.0
One sibling / One parent 4.6
One sibling / Two parents 7.1


  • Reference [5]
Race % of adults with diabetes
Non-hispanic white 7.1%
Asian-Americans 8.4%
Hispanics 11.8%
African Americans 12.6%















Reference [24]
A1C value 5-year incidence of T2DM
5.0 - 5.5% < 5 - 9%
5.5 - 6.0% 9 - 25%
6.0 - 6.5% 25 - 50%




ADA T2DM treatment recommendations
For diabetics with A1C < 9%
  • 1. Initial therapy for these patients should be the following:

  • 2. After 3 months, if blood sugar goals are not met, then add one of the following:

  • 3. After 3 months, if blood sugar goals are not met, then add a third drug from the list above
    • Special considerations:
      • For patients taking metformin + DPP-4 inhibitor: add sulfonylurea or glitazone or SGLT2 inhibitor or insulin
      • For patients taking metformin + SGLT2 inhibitor: add sulfonylurea or glitazone or DPP-4 inhibitor or insulin
      • For patients taking metformin + GLP-1 analog: add sulfonylurea or glitazone or insulin
      • For patients taking metformin + insulin: add glitazone or DPP-4 inhibitor or SGLT2 inhibitor or GLP-1 analog
      • For patients taking metformin + sulfonylurea: add any other med
      • For patients taking metformin + glitazone: add any other med

  • 4. After 3 months, if blood sugar goals are not met on three meds then consider the following:
    • If taking all oral meds, add insulin or GLP-1 analog
    • If using GLP-1 analog, add basal insulin
    • If on optimally titrated basal insulin, add GLP-1 analog or mealtime insulin [37]

For diabetics with A1C between 9 - 10%:

  • Use steps above, but consider initiating therapy with metformin and a drug from Step 2
For diabetics with A1C ≥ 10% and/or blood sugar ≥ 300 mg/dl:

  • Consider initiating therapy with the following:
    • Metformin + Basal insulin + Mealtime insulin or GLP-1 analog
    • After control is achieved, medication tapering may be attempted [37,38]

  • Reference [38]
ADA algorithm for initiating insulin in type two diabetes
Step 1 - start with basal insulin
  • Initial dose: 10 units/day OR 0.1 - 0.2 units/kg/day
  • Adjust dose: increase dose by 10 - 15% or 2 - 4 units once or twice weekly to achieve fasting blood sugar goal
  • If hypoglycemia occurs: decrease dose by 10 - 20% or 4 units

  • If blood sugars are still uncontrolled after fasting target is achieved or if insulin dose is > 0.5 units/kg/day, proceed to Step 2
    • Alternatively, may consider adding GLP-1 analog

Step 2 - add premeal insulin before largest meal
  • Initial dose: 4 units OR 0.1 units/kg OR 10% of basal dose
    • If A1C < 8%, consider decreasing basal insulin dose by same amount
  • Adjust dose: increase dose by 1 - 2 units or 10 - 15% once or twice weekly to achieve pre- and postprandial goals
  • If hypoglycemia occurs: decrease dose 2 - 4 units or 10 - 20%

    Alternative regimen - change basal insulin to twice daily premixed insulin
    • Initial dose: divide basal dose and give as premixed insulin twice daily (2/3 AM and 1/3 PM OR 1/2 AM and 1/2 PM)
    • Adjust dose: increase dose by 1 - 2 units or 10 - 15% once or twice weekly to achieve pre- and postprandial goals
    • If hypoglycemia occurs: decrease dose 2 - 4 units or 10 - 20%

  • If blood sugars are still uncontrolled, proceed to Step 3

Step 3 - add premeal insulin before ≥ 2 meals
  • Initial dose: 4 units OR 0.1 units/kg OR 10% of basal dose before each meal
    • If A1C < 8%, consider decreasing basal insulin dose by same amount
  • Adjust dose: increase dose by 1 - 2 units or 10 - 15% once or twice weekly to achieve pre- and postprandial goals
  • If hypoglycemia occurs: decrease dose 2 - 4 units or 10 - 20%

    Alternative regimen (twice daily premixed insulin):
    • Add additional injection before lunch
    • Adjust dose: increase dose by 1 - 2 units or 10 - 15% once or twice weekly to achieve pre- and postprandial goals
    • If hypoglycemia occurs: decrease dose 2 - 4 units or 10 - 20%