Achieving Control in Type 2 Diabetes

exp date isn't null, but text field is

Review diet, exercise and adherence to medication before making dose adjustments or prescribing additional therapy and discontinue new agents if no evidence of effectiveness at 3 to 6 months ie <5.5mmol/mol improvement in HbA1c

HbA1c target individualised as agreed ≤53mmol/mol on single agent,  ≤58mmol/mol on two or more agents

Patient factors

<25kg/m
OR 
osmotic symptoms of hyperglycaemia.  If weight loss check ketones.

>25kg/m2

Diet and exercise

1 month

(Treat immediately if symptomatic)

3 months

If appropriate, consider advising patients that remission of type 2 diabetes can be achieved with weight loss of 10 to 15kg

First-line oral therapy
(monotherapy)

SULFONYLUREA (SU)

METFORMIN (MET)

(SUs, SGLT2 inhibitors ("flozins").  DPP4 inhibitors ("gliptins") or PIO can all be used as alternate first line therapies in metformin intolerance)

Second-line oral therapy
(dual therapy)

SU + MET

MET + ONE of the following:

DPP-4 inhibitors ("gliptins")
Choose if weight gain and/or hypos are a concern.*

SU 
Choose if BMI <27kg/m2

PIOGLITAZONE (PIO) 
Choose if BMI <27kg/m2 and/or hypos are a concern.* See PIO prescribing algorithm.

SGLT2 inhibitors** ("flozins")
Choose if weight gain and/or hypos are a concern*.  

Note, do not initiate if eGFR<60mL/min.

Third-line oral therapy
(triple therapy)

Not appropriate – require INS initiation

MET + TWO of the following: 
(avoid combining PIO and dapagliflozin)

or consider injectable therapy eg insulin in BMI <30kg/m2, GLP1 therapy** if BMI >30kg/m2

DPP-4 inhibitors ("gliptins")
Choose if weight gain and/or hypos are a concern.*

 

SU 
Choose if BMI <27kg/m2

PIO 
Choose if BMI <27kg/m2 and hypos are a concern.* See PIO prescribing algorithm.

SGLT2 inhibitors** ("flozins")
Choose if weight gain and/or hypos are a concern.*  Note, do not initiate if eGFR <60ml/min.

GLP-1 therapy

Not appropriate

GLP1 may also be used with insulin:

  • stop DPP-4
  • consider reduction of SU dose on initiation
  • can continue metformin
  • can continue SGLT2 inhibitor ("flozin")
  • refer to GLP-1 protocol for further information.

Insulin therapies

 

Usually start with basal insulin at bed

  • Use NPH/isophane insulin eg Humulin I
  • Analogue insulin eg Insulin glargine, can be considered if high risk of hypoglycaemia or once daily administration by district nurse
  • Can continue metformin and/or SGLT2 inhibitor
  • Caution if on insulin (risk of fluid retention)
  • Consider reducing or stopping SU

 

* Falls in the elderly, driving, occupation, alcohol consumption.

** Favour SGLT2 inhibitors and GLP1 receptor agonists in individuals with known cardiovascular disease.

SU – sulfonylurea; MET – metformin; PIO – pioglitazone; SGLT2 – sodium-glucose co-transporter 2 inhibitor; DPP-4 – Dipeptidylpeptidase-4 inhibitor; GLP-1 – Glucagon-like peptide-1 analogue; INS – insulin; SMBG – self-monitoring of blood glucose.

<>Dose as in normal hepatic function

#Unless at individualised target. If treatment failure criteria not met on maximum tolerated dose consider withdrawal of medication, substitution or addition of another medication.

#Unless at individualised target. If treatment failure criteria not met on maximum tolerated dose consider withdrawal of medication, substitution or addition of another medication.

Editorial Information

Last reviewed: 30 August 2019

Next review: 30 August 2022

Author(s): Diabetes Review Group

Version: 11

Approved By: TAM Subgroup of ADTC

Reviewer Name(s): Diabetes Review Group

Document Id: TAM148