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 — 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

Recognise hypoglycaemia (sweating, shakiness, confusion); carry rapid-acting carbohydrate^[1]
Sick-day rules: continue insulin and metformin unless dehydrated; pause SGLT2 inhibitor with vomiting or dehydration^[1]
Foot inspection daily; annual eye examination; never walk barefoot^[1]

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.

References

1.RSSDI Clinical Practice Recommendations for Management of Type 2 Diabetes Mellitus (2022)

Drug

Class

Adult

Paediatric

Notes