Quick Overview
Type 2 diabetes (T2DM) accounts for 90% of diabetes cases, characterized by insulin resistance and progressive β-cell dysfunction. Management focuses on HbA1c control, cardiovascular risk reduction, and preventing microvascular complications. NICE NG28 emphasizes individualized targets and early cardiovascular protection.
Core Facts & Concepts
Diagnostic Criteria
- Fasting glucose ≥7.0 mmol/L OR random glucose ≥11.1 mmol/L
- HbA1c ≥48 mmol/mol (6.5%) - avoid if haemoglobinopathy, pregnancy, children
- Symptomatic: single test sufficient; asymptomatic: requires confirmation
HbA1c Targets (NICE NG28)
- Standard: 48 mmol/mol (6.5%) - lifestyle + single drug
- Intensified: 53 mmol/mol (7%) - on drug associated with hypoglycaemia
- Individualize for: frailty, life expectancy <10 years, high hypoglycaemia risk
Medication Contraindications
- Metformin: eGFR <30 mL/min, tissue hypoxia risk (heart failure, sepsis)
- SGLT2i: eGFR <20 mL/min, recurrent UTIs, DKA history
- GLP-1 RA: severe gastroparesis, pancreatitis history
- Sulfonylureas: avoid if hypoglycaemia risk (elderly, erratic eating)
- Pioglitazone: heart failure, bladder cancer, osteoporosis risk
Problem-Solving Approach
NICE NG28 Pharmacotherapy Algorithm
- First-line: Metformin (titrate to 2g/day, modified-release if GI intolerance)
- Dual therapy if HbA1c >58 mmol/mol after 3 months:
- CVD established or QRISK ≥10%: Add SGLT2i with proven CV benefit
- BMI ≥35: Consider GLP-1 RA (if HbA1c ≥58 after dual therapy)
- Otherwise: Add DPP-4i, pioglitazone, or sulfonylurea
- Triple therapy: Metformin + SGLT2i + third agent OR switch to insulin
🚩 Red Flags for Insulin Initiation
- Persistent hyperglycaemia despite triple therapy (HbA1c >75 mmol/mol)
- Symptomatic hyperglycaemia with weight loss (exclude T1DM/LADA)
- Acute illness, surgery, pregnancy
⚠️ Warning: SGLT2i carry DKA risk even with normal glucose ("euglycaemic DKA"). Stop during acute illness and perioperatively.
Analysis Framework
| Drug Class | HbA1c Reduction | Weight Effect | Hypo Risk | CV Benefit | Key Adverse Effect |
|---|---|---|---|---|---|
| Metformin | 10-20 mmol/mol | Loss/neutral | No | Neutral | GI upset, lactic acidosis |
| SGLT2i | 10-15 mmol/mol | Loss (2-3 kg) | No | Yes | Genital infections, DKA |
| GLP-1 RA | 15-20 mmol/mol | Loss (3-5 kg) | No | Yes | Nausea, pancreatitis |
| DPP-4i | 10 mmol/mol | Neutral | No | Neutral | Well tolerated |
| Sulfonylureas | 15-20 mmol/mol | Gain | Yes | No | Hypoglycaemia, weight gain |
| Pioglitazone | 10-15 mmol/mol | Gain | No | Neutral | Fluid retention, fractures |
Cardiovascular Risk Management (as important as glycaemic control)
- Statin: Atorvastatin 20 mg for all T2DM (primary prevention)
- ACEi/ARB: If hypertension, albuminuria, or age >55 with CV risk factors
- Antiplatelet: Aspirin 75 mg if CVD established (NOT primary prevention)
Visual Aid
Key Points Summary
✓ Diagnosis: HbA1c ≥48 mmol/mol, fasting glucose ≥7.0 mmol/L (confirm if asymptomatic)
✓ Targets: 48 mmol/mol (lifestyle + single drug), 53 mmol/mol (if hypoglycaemia risk)
✓ First-line: Metformin 2g/day; contraindicated if eGFR <30 mL/min
✓ CVD protection: Add SGLT2i if established CVD or QRISK ≥10% (regardless of HbA1c)
✓ GLP-1 RA: Consider if BMI ≥35 and HbA1c >58 mmol/mol despite dual therapy
✓ Avoid sulfonylureas: High hypoglycaemia risk in elderly, erratic eating patterns
✓ Annual screening: Retinopathy (fundoscopy), nephropathy (ACR), neuropathy (monofilament), foot examination
📌 Remember: METFORMIN - Metformin first, EGFR check, Target individualized, Foot checks, Ophthalmology referral, Risk CV assessment, Monitor HbA1c 3-6 monthly, Insulin if triple therapy fails, Nephropathy screening (ACR)
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