Patient with type 2 diabetes and HbA1c above target. Action: assess the profile (renal function, age, hypoglycaemia risk, cardiovascular disease), start metformin as first line unless contraindicated and add a targeted second agent if the target is not reached.
Ketoacidosis (nausea, vomiting, abdominal pain, Kussmaul breathing), severe hypoglycaemia with altered consciousness, diabetic foot ulcer or vision loss → refer immediately.
Target HbA1c (usually <7%, individualised), renal function (eGFR), BMI, history of cardiovascular disease, hypoglycaemia risk and patient preferences.
Unless contraindicated, start metformin and titrate gradually (500–2000 mg/day) to reduce gastrointestinal effects. Check renal function before starting.
If HbA1c remains above target after 3 months (or very high at presentation): SGLT2i or GLP1-RA in patients with cardiovascular disease or high risk; sulphonylurea or DPP4i depending on profile and cost.
Review HbA1c and adherence every 3 months. Teach hypoglycaemia signs, annual foot review, retinal surveillance and vaccination.
Metformin: stop if eGFR < 30 mL/min and use with caution between 30–45. Sulphonylureas and insulin increase the risk of hypoglycaemia — teach the patient the warning signs. SGLT2i and GLP1-RA are not recommended in pregnancy.
DGS Guideline — Therapeutic Approach to Type 2 Diabetes Mellitus
Official source