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]
First-line treatment
Interventions
- 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
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 | 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 |
| SGLT2 inhibitor (one of the listed dual-therapy options)[1] | SGLT2 inhibitor | No SGLT2 inhibitor dose is stated in this STW. | — | The July 2022 ICMR STW lists an SGLT2 inhibitor as one of six unranked options to combine with metformin at HbA1c 8.5–10%. This STW does not state an HF, CKD or CVD preference. |
| 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) | Insulin therapy | Glargine 0.1–0.2 U/kg once daily basal; premix BD when basal alone insufficient | — | For initial HbA1c >10%, the July 2022 ICMR STW lists basal insulin plus metformin plus another oral antidiabetic drug, or a triple oral-drug combination. [1] |
Metformin[1]
Biguanide
- Adult
- 500 mg PO daily, titrate to 1 g BD; max 2 g/day; avoid if eGFR <30
- Paediatric
- 10–17 yrs: 500 mg–2 g daily
First-line for all T2DM unless contraindicated
Sulfonylurea (gliclazide)[1]
Insulin secretagogue
- Adult
- Gliclazide 30–120 mg PO daily (sustained release)
- Paediatric
- —
Cost-effective add-on; risk of hypoglycaemia and weight gain; widely available across primary care
SGLT2 inhibitor (one of the listed dual-therapy options)[1]
SGLT2 inhibitor
- Adult
- No SGLT2 inhibitor dose is stated in this STW.
- Paediatric
- —
The July 2022 ICMR STW lists an SGLT2 inhibitor as one of six unranked options to combine with metformin at HbA1c 8.5–10%. This STW does not state an HF, CKD or CVD preference.
Sitagliptin or teneligliptin (DPP-4 inhibitor)[1]
DPP-4 inhibitor
- Adult
- Sitagliptin 100 mg or teneligliptin 20 mg PO once daily
- Paediatric
- —
Weight-neutral, low hypoglycaemia risk; widely available; often combined with metformin
Insulin (glargine, NPH, premix)
Insulin therapy
- Adult
- Glargine 0.1–0.2 U/kg once daily basal; premix BD when basal alone insufficient
- Paediatric
- —
For initial HbA1c >10%, the July 2022 ICMR STW lists basal insulin plus metformin plus another oral antidiabetic drug, or a triple oral-drug combination. [1]
Safety-net
- 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]
Referral criteria
- 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]
Clinical summary
Diagnosis and stepped pharmacotherapy of T2DM per ICMR Standard Treatment Workflow — primary-care-focused stepped therapy with metformin first-line.