Website last updated 29/06/2025
Type 2 Diabetes (18 years +)
- Mental Health. Patient's with T2DM are 2-3 times more likely to suffer with depression. Mental health should be assessed at each review
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Every patient should have an annual medication review, blood tests, foot check, and ACR. ​​
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- There’s a clear link between weight and blood sugar. Weight loss can reduce HbA1c, and treatment may need adjustment with significant weight changes.
-Aim for tight HbA1c control in newly diagnosed and younger diabetics, as this leads to better cardiovascular outcomes.
- Blood sugar monitor testing is not needed unless the patient is at a high risk of hypoglycaemia (for example on glicliazide)
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- All patients should be offered a structured education program ​
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- Patients should undergo a diabetic eye examination at least once every two years.​
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- Most T2DM patients will eventually require insulin
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-Sudden or unexplained weight loss can occur if cells are unable to metabolise glucose. This can indicate that the patient requires insulin treatment.
- Metformin is the first line medication
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- Patient's should have their HbA1c levels checked 3 months after
- Initiating treatment
- Titrating any current treatment
- Stopping treatment
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-Some patients may choose to attempt weight loss before starting a new antidiabetic medication or increasing the dose of their current one
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- These patient's should have a HbA1c blood test after 2-3 months. If they fail to reduce their HbA1c naturally, you should advise treatment intensification ​
- Measure the patient's HbA1c 3-6 months after initiating a new medication or titrating a dose of a current medication ​
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- Aim for the target HbA1c as per the table above
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- Consider discontinuing any treatment that does not reduce the patient's HbA1c by 5.5mmol/mol in 3-6 months
- Treatment choice should take into consideration the factors in the table below
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- Choice of medication is patient dependent, for example if HbA1c is mildly elevated, you may consider a DPP-4 inhibitor as there are less adverse effects
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- If HbA1c is very high, you may consider a sulfonylurea to quickly reduce the patient's HbA1c.
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- If HbA1c levels do not reach the target after trialing an antidiabetic medication, you can consider either:
- adding on another antidiabetic
- switching to a more potent antidiabetic (if patient is having side effects from the current treatment or prefers to have less medications or would be unlikely to adhere to multiple therapy).
- ACEi or ARB drugs are first line for hypertension in diabetes as they have a kidney protection effect
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- 140/90mmHg target clinic blood pressure
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- 130/80mmHg target for people with :
- CKD and diabetes
- an ACR of 70 mg/mmol or more
- If patient has a blood glucose monitor, advise to increase monitoring frequency to every 2-4 hours
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- If patient does not have a monitor, advise them to look out for symptoms of high blood glucose. These include thirst, passing more urine than usual and tiredness. (seek medical attention)
- Do not stop insulin treatment
- Stay hydrated and try to maintain usual calorie intake
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- Which medications to pause:
- Metformin (risk of dehydration/lactic acidosis)
- Sulfonylureas (risk of hypoglycaemia)
- GLP-1 medications (risk of dehydration)
- SGLT2 inhibitors (risk of dehydration/DKA)
- ACEi/ARBs - risk of kidney damage
- Diuretics - risk of dehydration
- NSAIDs - risk of kidney damage
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- Medications can be restarted 24-48 hours after patient is feeling well
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- If patient is on a medication that carries a risk of hypoglycaemia, advise on what to do if they experience a hypo:
- If blood sugar levels less than 4mmol/l, have 15-20g fast acting carbs. Once hypo has been treated, have 15-20g slow acting carbs.
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- If on SGLT2 advise visit A&E/call 999 if symptoms of DKA: sweet smelling breath, deep breathing, drowsiness, stomach pain, nausea, vomiting, blurred vision.​
Why aren't lower HbA1c targets recommended?
Studies have shown that some patients with lower HbA1cs were at a higher cardiovascular risk
How do I mange the GI side effects from metformin?
The first option would be to switch the the modified release form as this may improve gastro-intestinal tolerability