Type 2 diabetes in adults

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 — significant evidence-care gap; 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]
Pregnancy in T2DM — switch most oral agents (sulfonylureas, SGLT2i, GLP-1 RA) to insulin pre-conception or on confirmation^[1]

Structured diabetes education^[1]
Group or individual structured education at diagnosis and annually; reduces HbA1c and complications
Lifestyle: diet + activity^[1]
Plant-based or low-glycaemic-load diet, 5–10% weight loss target if overweight, ≥150 min/week aerobic activity, smoking cessation
Annual complications surveillance^[1]
Eye, foot, kidney, cardiovascular, mental health screening annually

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	10–17 yrs: 500 mg–2 g daily	First-line for all T2DM unless contraindicated
Sulfonylurea (gliclazide)^[1]	Insulin secretagogue	Gliclazide 30–120 mg PO daily (sustained release)	—	Cost-effective add-on; risk of hypoglycaemia and weight gain; widely available across primary care
Empagliflozin or dapagliflozin^[1]	SGLT2 inhibitor	Empagliflozin 10–25 mg or dapagliflozin 10 mg PO once daily	—	Add for established CVD, heart failure, or CKD; cardio-renal protection
Sitagliptin or teneligliptin (DPP-4 inhibitor)^[1]	DPP-4 inhibitor	Sitagliptin 100 mg or teneligliptin 20 mg PO once daily	—	Weight-neutral, low hypoglycaemia risk; widely available; often combined with metformin
Insulin (glargine, NPH, premix)^[1]	Insulin therapy	Glargine 0.1–0.2 U/kg once daily basal; premix BD when basal alone insufficient	—	Add when oral therapies fail or HbA1c >9% at diagnosis; structured education essential

Metformin^[1]

Biguanide

First-line for all T2DM unless contraindicated

Sulfonylurea (gliclazide)^[1]

Insulin secretagogue

Cost-effective add-on; risk of hypoglycaemia and weight gain; widely available across primary care

Empagliflozin or dapagliflozin^[1]

SGLT2 inhibitor

Add for established CVD, heart failure, or CKD; cardio-renal protection

Sitagliptin or teneligliptin (DPP-4 inhibitor)^[1]

DPP-4 inhibitor

Weight-neutral, low hypoglycaemia risk; widely available; often combined with metformin

Insulin (glargine, NPH, premix)^[1]

Insulin therapy

Adult: Glargine 0.1–0.2 U/kg once daily basal; premix BD when basal alone insufficient
Paediatric: —

Add when oral therapies fail or HbA1c >9% at diagnosis; structured education essential

Recognise hypoglycaemia (sweating, shakiness, confusion) — carry rapid-acting carbohydrate; severe episodes need urgent care^[1]
Sick-day rules: continue insulin and metformin during illness unless dehydrated; pause SGLT2 inhibitor with vomiting/dehydration^[1]
Foot inspection daily; never walk barefoot; report new ulcers within a week^[1]

DKA, HHS, or severe hypoglycaemiaEmergency department / ICU^[1]
T2DM in pregnancy or planning pregnancyJoint diabetes-obstetric care^[1]
Symptomatic with HbA1c >10% at diagnosisDiabetes specialist; consider initial insulin^[1]
Diabetic foot ulcer, retinopathy, or progressive nephropathySpecialist diabetic foot service / ophthalmology / nephrology^[1]

Diagnosis and stepped pharmacotherapy of T2DM per ICMR Standard Treatment Workflow — primary-care-focused stepped therapy with metformin first-line.

1.ICMR Standard Treatment Workflows — Diabetes Mellitus Type 2; ICMR Guidelines for Management of T2DM (2022)