These guidelines are broadly based upon on ADA/EASD guidelines from 2022, with some Tayside specific modification.

 

Click on here for full ADA/EASG guidelines

 

 

 

  

STEP 1: Comprehensive Lifestyle Management

 

• Includes weight management (Oviva Diabetes Support), Counterweight weight management clinic (if BMI>35kg/m²)
• Other lifestyle measures including physical activity, smoking cessation, alcohol management
• These issues should always be addressed at every step in the management plan below, but don’t necessarily need to result in a delay in treatment.

 

 STEP 2: Metformin

 

• Consider initiation at diagnosis if HbA1c high
• If eGFR <45ml/min reduce dose to 500mg bd
• If eGFR <30ml/min stop

 

 STEP 3: Do they have a history of Atherosclerotic Cardiovascular Disease, CKD or Heart

             Failure?  Or are they high risk for cardiovascular disease

 

If no go to 3.1;  If yes go to 3.2

 

3.1 No Evidence of Atherosclerotic Cardiovascular Disease, CKD or Heart Failure

 

If HbA1c is above individualised target then choose any one of the following:

1. SGLT2 inhibitor* e.g. Dapagliflozin, Empagliflozin
2. DPP-4 inhibitor e.g. Sitagliptin
3. Sulphonylurea and blood glucose monitoring e.g. Gliclazide MR
4. Thiazolidinedione ie pioglitazone
5. GLP-1RA** e.g. Semaglutide sc or oral see Initiation of Oral GLP-1 in Primary Care

 

If further HbA1c lowering is required then the other agents can be added in except that a DPP-4 inhibitor should NOT be combined with a GLP1RA as they work on the same glucose lowering pathway.

 

If weight loss is a major need then prioritise the following, which can be combined

1. SGLT2 inhibitor* eg Dapagliflozin, Empagliflozin
2. GLP-1RA** e.g. Semaglutide sc or oral see Initiation of Oral GLP-1 in Primary Care

 

3.2: Presence of Atherosclerotic Cardiovascular Disease, CKD or Heart Failure

Independent of baseline HbA1c or target HbA1c:

 

3.2.1  CKD (defined as eGFR<60, twice, 3 months apart; or UACR>20mg/mmol on two of the last 3 measures).  Add SGLT2i* with primary evidence of reducing CKD progression (e.g. Dapagliflozin) if eGFR>20ml/min.   Add/optimize ACE/ARB and statin.

 

3.2.2  History of heart failure.  Add SGLT2i* with proven benefit of reducing HF progression (e.g. Dapagliflozin or Empagliflozin) if eGFR>20ml/min.  If known HFrEF then add/optimize ACE/ARB and consider low dose beta-blocker. 

 

3.2.3  History of CVD (MI, CABG, PCI, ACS, Stroke, TIA, PVD) or High risk for CVD (>55 years and two or more additional risk factors including obesity, hypertension, smoking, dyslipidemia, albuminuria) then add either an SGLT2i* with proven CVD benefit (e.g. Empagliflozin or Dapagliflozin) if eGFR>20ml/min OR add a GLP-1RA with proven CVD benefit (e.g. Semaglutide, Dulaglutide or Liraglutide).   An SGLT2i is preferable if the UACR is persistently >3mg/mmol; a GLP-1RA is preferable if the patient has had a prior stroke/TIA.

 

If HbA1c remains elevated after >4 months then add an SGLT2i if already treated with a GLP-1RA, or add a GLP-1RA** if already treated with an SGLT2i. See Initiation of Oral GLP-1 in Primary Care

 

Then add in agents described in section 3.1.

 

STEP 4: Add in Insulin

 

Insulin can cause weight gain and has no evidence for cardiovascular protection.  Insulin is not the best treatment for people with type-2 diabetes (especially if they are overweight), but may be a necessary agent if other treatments fail to control the glycaemia adequately. If the patient is not treated with a GLP-1RA and is obese initiate a GLP-1RA first, and consider escalation to a GLP-1RA/insulin fixed dose combination. 

 

Usually start basal insulin and add prandial insulin later

 

*Stopping SGLT2 inhibitors during periods of acute illness/surgery

*SGLT2 Inhibitor Patient Information

 

**Due to ongoing unpredictable and evolving supply issues with both oral and injectable GLP-1R Agonist drugs please consider the following.