Red Flags
- Hyperglycaemic emergency: DKA, HHS, severe hypoglycaemia — emergency department; IV fluids, insulin infusion, electrolyte correction[1]
- Symptoms of HHS in older T2DM (severe hyperglycaemia >600 mg/dL, hyperosmolarity, no significant ketones) — ICU; cautious fluid and insulin[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]
- Pregnancy in T2DM — switch sulfonylureas, SGLT2 inhibitors, GLP-1 RAs to insulin pre-conception or on confirmation[1]
First-line treatment
Interventions
- Structured diabetes education (DESMOND, Dose Adjustment for Normal Eating)[1]Group or individual structured education at diagnosis and annually; improves glycaemic control and reduces complications
- Lifestyle: dietary patterns + activity[1]Mediterranean or low-carbohydrate diet, 5–10% weight loss target if overweight, ≥150 min/week moderate aerobic activity, smoking cessation, alcohol moderation
- Annual complications surveillance[1]Eye, foot, kidney, cardiovascular, mental health screening annually; structured care reduces complications
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Metformin[1] | Biguanide | 500 mg PO daily, titrate to 1 g BD over 4–8 weeks; max 2 g/day; avoid if eGFR <30 | 10–17 years: 500 mg–2 g daily | First-line for all T2DM unless contraindicated; weight-neutral, no hypoglycaemia, mortality benefit per UKPDS |
| Empagliflozin or dapagliflozin[1] | SGLT2 inhibitor | Empagliflozin 10–25 mg PO once daily; dapagliflozin 10 mg PO once daily | — | First-line addition or alternative to metformin in established CVD, heart failure, or CKD; cardio-renal protection independent of glycaemic effect |
| Semaglutide or dulaglutide (GLP-1 RA)[1] | GLP-1 receptor agonist | Semaglutide 0.25 mg SC weekly titrate to 1–2 mg; dulaglutide 0.75 mg SC weekly titrate to 1.5–4.5 mg | — | Add for established ASCVD, weight reduction priority, or HbA1c not at target on metformin + SGLT2i |
| Sulfonylurea (gliclazide)[1] | Insulin secretagogue | Gliclazide 30–120 mg PO daily (sustained release) | — | Cost-effective add-on when SGLT2/GLP-1 unavailable; risk of hypoglycaemia and weight gain; DPP-4 inhibitor (sitagliptin/teneligliptin) is alternative weight-neutral oral |
| Basal insulin (glargine, detemir, degludec)[1] | Long-acting insulin analogue | Start 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 to reach HbA1c target; basal-only often sufficient for many years before basal-bolus |
Metformin[1]
Biguanide
- Adult
- 500 mg PO daily, titrate to 1 g BD over 4–8 weeks; max 2 g/day; avoid if eGFR <30
- Paediatric
- 10–17 years: 500 mg–2 g daily
First-line for all T2DM unless contraindicated; weight-neutral, no hypoglycaemia, mortality benefit per UKPDS
Empagliflozin or dapagliflozin[1]
SGLT2 inhibitor
- Adult
- Empagliflozin 10–25 mg PO once daily; dapagliflozin 10 mg PO once daily
- Paediatric
- —
First-line addition or alternative to metformin in established CVD, heart failure, or CKD; cardio-renal protection independent of glycaemic effect
Semaglutide or dulaglutide (GLP-1 RA)[1]
GLP-1 receptor agonist
- Adult
- Semaglutide 0.25 mg SC weekly titrate to 1–2 mg; dulaglutide 0.75 mg SC weekly titrate to 1.5–4.5 mg
- Paediatric
- —
Add for established ASCVD, weight reduction priority, or HbA1c not at target on metformin + SGLT2i
Sulfonylurea (gliclazide)[1]
Insulin secretagogue
- Adult
- Gliclazide 30–120 mg PO daily (sustained release)
- Paediatric
- —
Cost-effective add-on when SGLT2/GLP-1 unavailable; risk of hypoglycaemia and weight gain; DPP-4 inhibitor (sitagliptin/teneligliptin) is alternative weight-neutral oral
Basal insulin (glargine, detemir, degludec)[1]
Long-acting insulin analogue
- Adult
- Start 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 to reach HbA1c target; basal-only often sufficient for many years before basal-bolus
Safety-net
- Recognise hypoglycaemia (sweating, shakiness, confusion) — carry rapid-acting carbohydrate; severe episodes need glucagon or A&E[1]
- Sick-day rules: do not stop insulin or metformin (unless dehydrated); SGLT2 inhibitor should be paused with vomiting or dehydration to avoid euglycaemic DKA[1]
- Foot inspection daily; report new ulcers same week; never walk barefoot[1]
Referral criteria
- DKA, HHS, or severe hypoglycaemiaEmergency department / ICU[1]
- T2DM in pregnancy or planning pregnancyJoint diabetes-obstetric care[1]
- Symptomatic with HbA1c >86 mmol/mol (10%) at diagnosisDiabetes specialist; consider initial insulin[1]
- Established ASCVD, HF, or CKD without SGLT2i / GLP-1 RADiabetes / cardiology / nephrology for evidence-based add-on therapy[1]
Clinical summary
Diagnosis and stepped pharmacotherapy of T2DM per NICE NG28 — metformin first-line, SGLT2 inhibitors and GLP-1 RAs for cardio-renal protection.