Tayside Diabetes MCN Handbook

Pharmacological Management of Type 2 Diabetes



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.

  • we have to assume that no GLP-1RA drugs will be available for the rest of 2023 and possibly beyond
  • going forward there is no point in changing patients from one GLP-1RA drug to another as this will have knock on effects and lead to the point above occurring more rapidly
  • there are options within the diabetes prescribing guidelines to use other drug types in people with type 2 diabetes which are suitable and have not already been trialled for that patient.
In people taking GLP-1RA drugs where supply becomes an issue there is no action needed as an emergency to replace this drug with another and we propose that the following pragmatic process should be considered:
  • general review of the person with diabetes, encouraging diet and lifestyle review and support to maintain glycaemic control and avoid weight gain
  • review of HbA1c after 3 months without the GLP-1RA drug with reference to the supply situation at that time and recognised diabetes prescribing guidelines
  • seeking specialist advice at that point if considered necessary and appropriate