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 — initiate at next visit[1]
- Diabetic foot ulcer with deep involvement, ischaemia, or systemic features — multidisciplinary diabetic foot service same-day[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 + dietitian referral[1]Indian-cuisine-aware medical nutrition therapy; group or individual structured programmes
- Physical activity ≥150 min/week + resistance training 2/week[1]Adapt to local feasibility (walking, yoga, household activity); reduces HbA1c and CVD risk
- Annual complications surveillance[1]Eye, foot, kidney, cardiovascular screening annually; reduces complications burden
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 | — | First-line for all T2DM unless contraindicated; widely available cost-effective |
| Glimepiride or gliclazide (SU)[1] | Sulfonylurea | Glimepiride 1–4 mg or gliclazide 30–120 mg PO daily (SR) | — | Cost-effective add-on; available across primary care; hypoglycaemia and weight gain risks |
| Sitagliptin or teneligliptin or vildagliptin (DPP-4i)[1] | DPP-4 inhibitor | Sitagliptin 100 mg, teneligliptin 20 mg, or vildagliptin 50 mg BD PO daily | — | Weight-neutral, low hypoglycaemia risk; commonly combined with metformin |
| Empagliflozin or dapagliflozin[1] | SGLT2 inhibitor | Empagliflozin 10–25 mg or dapagliflozin 10 mg PO once daily | — | Class I in ASCVD, HF, or CKD; cardio-renal protection |
| Pioglitazone[1] | Thiazolidinedione (TZD) | 15–45 mg PO once daily | — | Insulin sensitiser; useful in NAFLD; weight gain and fluid retention; avoid in heart failure or osteoporosis |
| Insulin (glargine, NPH, premix)[1] | Insulin therapy | Glargine 0.1–0.2 U/kg once daily basal; premix BD for combined basal-prandial coverage | — | Add when oral therapies fail or HbA1c >9% at diagnosis with symptoms |
Metformin[1]
Biguanide
- Adult
- 500 mg PO daily, titrate to 1 g BD; max 2 g/day; avoid if eGFR <30
- Paediatric
- —
First-line for all T2DM unless contraindicated; widely available cost-effective
Glimepiride or gliclazide (SU)[1]
Sulfonylurea
- Adult
- Glimepiride 1–4 mg or gliclazide 30–120 mg PO daily (SR)
- Paediatric
- —
Cost-effective add-on; available across primary care; hypoglycaemia and weight gain risks
Sitagliptin or teneligliptin or vildagliptin (DPP-4i)[1]
DPP-4 inhibitor
- Adult
- Sitagliptin 100 mg, teneligliptin 20 mg, or vildagliptin 50 mg BD PO daily
- Paediatric
- —
Weight-neutral, low hypoglycaemia risk; commonly combined with metformin
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; cardio-renal protection
Pioglitazone[1]
Thiazolidinedione (TZD)
- Adult
- 15–45 mg PO once daily
- Paediatric
- —
Insulin sensitiser; useful in NAFLD; weight gain and fluid retention; avoid in heart failure or osteoporosis
Insulin (glargine, NPH, premix)[1]
Insulin therapy
- Adult
- Glargine 0.1–0.2 U/kg once daily basal; premix BD for combined basal-prandial coverage
- Paediatric
- —
Add when oral therapies fail or HbA1c >9% at diagnosis with symptoms
Safety-net
Referral criteria
- DKA, HHS, or severe hypoglycaemiaEmergency department / ICU[1]
- T2DM in pregnancy or planning pregnancyJoint diabetes-obstetric care[1]
- Diabetic foot ulcer or critical limb ischaemiaMultidisciplinary diabetic foot service[1]
- HbA1c >10% with symptoms at diagnosis or refractory hyperglycaemiaDiabetes specialist for insulin initiation[1]
Clinical summary
RSSDI clinical practice recommendations for T2DM — stepped therapy with attention to NLEM-available drugs, primary-care feasibility, and cardiometabolic protection.