Pharmacotherapy and Glycemic Targets
Glycemic targets
For many nonpregnant adults the A1c goal is <7%, with preprandial glucose 80-130 mg/dL and peak postprandial <180 mg/dL. Individualize: a less stringent goal (<8%) suits limited life expectancy, severe hypoglycemia risk, advanced complications, or frailty; a tighter goal (<6.5%) may fit newly diagnosed, long life expectancy, and low hypoglycemia risk, provided it is achieved without burden. A1c is an average, not a measure of variability or hypoglycemia.
Medication logic
Metformin remains first-line for type 2 diabetes when tolerated and not contraindicated. Do not initiate metformin at eGFR <45; discontinue at eGFR <30; hold around iodinated contrast when eGFR is 30-60 and recheck renal function in 48 hours. For patients with atherosclerotic cardiovascular disease, heart failure, or chronic kidney disease, add an SGLT2 inhibitor and/or GLP-1 receptor agonist with proven benefit, independent of A1c or metformin use. Insulin is required for type 1 diabetes and for symptomatic or catabolic type 2 presentations (A1c >10%, glucose ≥300, ketosis). Sulfonylureas and insulin carry hypoglycemia risk; SGLT2 inhibitors carry genital mycotic infection, volume depletion, and euglycemic ketoacidosis risk.
Traps
Questions often test drug-disease mismatch, such as an SGLT2 inhibitor in recurrent genital infections, or a sulfonylurea in an older adult with erratic meals. Fixing one number with a drug that causes hypoglycemia is not a correct answer. Do not stop metformin for mild eGFR decline without checking the threshold.
Rule of thumb
Choose therapy in this order: comorbidity-driven indication first, hypoglycemia risk and renal function second, cost and adherence third, A1c-lowering potency last.