Red Flags
- Hyperglycaemic emergency: DKA, HHS, severe hypoglycaemia — emergency department; IV fluids, insulin, electrolyte correction[1]
- T2DM with established CVD or high CV risk not on SGLT2 inhibitor or GLP-1 RA — guideline-discordant; initiate at next visit[1]
- T2DM with new heart failure or CKD — initiate SGLT2 inhibitor regardless of HbA1c; cardio-renal protection independent of glycaemic effect[1]
- Severe hypoglycaemia in elderly or frail — relax HbA1c target to <8% or individualised; reduce insulin/sulfonylurea[1]
First-line treatment
Interventions
- Holistic person-centred care[1]ADA/EASD framework: cardiovascular risk reduction is the primary objective alongside glycaemic management; weight, BP, lipids, lifestyle, mental health all addressed simultaneously
- Lifestyle: diet, activity, sleep, smoking, alcohol[1]Mediterranean / DASH / low-carbohydrate diet; 5–10% weight loss target; ≥150 min/week aerobic activity; smoking cessation
- Annual complications surveillance[1]Eye, foot, kidney, cardiovascular, mental health, dental, sexual function screening annually
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Metformin[1] | Biguanide | 500 mg PO daily, titrate to 1 g BD; max 2 g/day; avoid if eGFR <30 | — | Foundation therapy unless contraindicated; combine from outset with SGLT2i or GLP-1 RA in high-CV-risk patients |
| Empagliflozin or dapagliflozin[1] | SGLT2 inhibitor | Empagliflozin 10–25 mg or dapagliflozin 10 mg PO once daily | — | Class I in ASCVD, HF, or CKD regardless of HbA1c; consider in stage 3 CKD with eGFR ≥20 |
| Semaglutide or tirzepatide[1] | GLP-1 receptor agonist or GIP/GLP-1 agonist | Semaglutide 0.25 mg SC weekly titrate to 1–2 mg; tirzepatide 2.5 mg SC weekly titrate to 5–15 mg | — | Class I in ASCVD; significant weight reduction; tirzepatide superior glycaemic and weight effect per SURPASS |
| Sulfonylurea (glimepiride or gliclazide)[1] | Insulin secretagogue | Glimepiride 1–4 mg PO daily; gliclazide 30–120 mg PO daily (SR) | — | Cost-effective add-on when SGLT2i/GLP-1 unavailable; hypoglycaemia and weight gain risks |
| Basal insulin (glargine, degludec)[1] | Long-acting insulin analogue | 0.1–0.2 U/kg once daily; titrate by 2 units every 3 days to fasting glucose target | — | Add when oral therapies + GLP-1 fail; basal-only often sufficient for years before basal-bolus |
Metformin[1]
Biguanide
- Adult
- 500 mg PO daily, titrate to 1 g BD; max 2 g/day; avoid if eGFR <30
- Paediatric
- —
Foundation therapy unless contraindicated; combine from outset with SGLT2i or GLP-1 RA in high-CV-risk patients
Empagliflozin or dapagliflozin[1]
SGLT2 inhibitor
- Adult
- Empagliflozin 10–25 mg or dapagliflozin 10 mg PO once daily
- Paediatric
- —
Class I in ASCVD, HF, or CKD regardless of HbA1c; consider in stage 3 CKD with eGFR ≥20
Semaglutide or tirzepatide[1]
GLP-1 receptor agonist or GIP/GLP-1 agonist
- Adult
- Semaglutide 0.25 mg SC weekly titrate to 1–2 mg; tirzepatide 2.5 mg SC weekly titrate to 5–15 mg
- Paediatric
- —
Class I in ASCVD; significant weight reduction; tirzepatide superior glycaemic and weight effect per SURPASS
Sulfonylurea (glimepiride or gliclazide)[1]
Insulin secretagogue
- Adult
- Glimepiride 1–4 mg PO daily; gliclazide 30–120 mg PO daily (SR)
- Paediatric
- —
Cost-effective add-on when SGLT2i/GLP-1 unavailable; hypoglycaemia and weight gain risks
Basal insulin (glargine, degludec)[1]
Long-acting insulin analogue
- Adult
- 0.1–0.2 U/kg once daily; titrate by 2 units every 3 days to fasting glucose target
- Paediatric
- —
Add when oral therapies + GLP-1 fail; basal-only often sufficient for years before basal-bolus
Safety-net
- Recognise hypoglycaemia and carry rapid-acting carbohydrate; severe episodes need urgent care[1]
- Sick-day rules: continue insulin and metformin unless dehydrated; pause SGLT2 inhibitor with vomiting or dehydration[1]
- Annual eye and foot screening prevents blindness and amputation — never skip these even when feeling well[1]
Referral criteria
- DKA, HHS, or severe hypoglycaemiaEmergency department / ICU[1]
- T2DM in pregnancy or planning pregnancyJoint diabetes-obstetric care[1]
- Established ASCVD, HF, or CKD without SGLT2i or GLP-1 RADiabetes specialist for therapy intensification[1]
- HbA1c >10% at diagnosis or symptomatic hyperglycaemiaDiabetes specialist; consider initial insulin[1]
Clinical summary
ADA/EASD consensus on holistic, person-centred glycaemic and cardiometabolic management of T2DM with cardio-renal protection emphasised over HbA1c-only target.