Questionnaire/history: Polydipsia? Polyuria? Blurred vision? Unexplained weight loss? Recurrent infections? Tiredness? Risk factors? Past medical history? Family history? Current medication? Drug allergies? Investigations: HbA1c ≥ 48 mmol/mol (6/5%)? Fasting plasma glucose ≥ 7 mmol/mmol? Random plasma glucose ≥ 11.1 in the presence of symptoms or signs of diabetes? Diagnosis: Symptomatic and a single abnormal HbA1c or fasting plasma glucose level? Asymptomatic and repeated abnormal HbA1c or fasting plasma glucose level? Management: Offered referral to a structured group education programme such as the Diabetes Education for Self-Management for Ongoing and Newly Diagnosed (DESMOND) programme? Assessed for anxiety and depression and managed appropriately? Offered seasonal influenza and pneumococcal immunization? Screening for complications at diagnosis and then annually? HbA1 measurements in 3–6-monthly intervals initially until stable on unchanging antidiabetic treatment and then 6 monthly to ensure adequate blood glucose control? Targets: Lifestyle +/- single drug not associated with hypoglycaemia (eg metformin): 48 mmol/mol (6.5%)? Drug treatment associated with hypoglycaemia (eg sulfonylurea): 53 mmol/mol (7.0%)? If not adequately controlled by a single drug and rise to 58 mmol/mol (7.5%) or higher? - Reinforced advice on lifestyle? - Assessed person’s adherence to drug treatment? - Intensified drug treatment, if appropriate? Drug treatment: First line: If symptomatic: Need for immediate insulin or sulfonylurea depending on specialist advice? Otherwise: Standard-release metformin (MF) unless contraindicated with gradually increase of the dose over several weeks to minimise the risk of adverse side effects (if intolerable gastrointestinal side effects consider a trial of modified‑release metformin) and monitoring of renal function before and during treatment with metformin (avoid if eGFR < 30 ml/minute/1.73m2)? MF contraindicated of not tolerated? Dipeptidyl peptidase-4 inhibitor (DPP-4i)? Pioglitazone? Sulfonylurea (SU)? Sodium-glucose cotransporter-2 inhibitor (SGLT2i) instead of DPP-4i if pioglitazone and SU not appropriate? Chronic heart failure and/or established atherosclerotic cardiovascular disease? SGLT2i with proven cardiovascular benefit in addition to current treatment or replaced existing drug with the SGLT2i? Second line: MF + DPP4i? MF + pioglitazone? MF + SU? MF + SGLT-2i if SU contraindicated or not tolerated or significant risk of hypoglycaemia? MF contraindicated or not tolerated? DPP4i + pioglitazone DPP4i + SU Pioglitazone + SU Third-line: MF + DPP4i + SU? MF + pioglitazone + SU? MF + pioglitazone or SU + SGLT2i canagliflozin or empagliflozin (dapagliflozin only with MF + SU)? MF + DDP4i + SGLT2i ertugliflozin only if pioglitazone or SU not appropriate? Insulin (Note: If MF is contraindicated or not tolerated and if dual therapy with 2 oral drugs has not continued to control HbA1c to below the person's individually agreed threshold for intensification, consider insulin‑based treatment) If triple therapy ineffective, contraindicated or not tolerated: Triple therapy with MF? MF + SU + glucagon-like peptide-1 receptor agonist (GLP-1 RA) if: - BMI ≥ 35 kg/m2 - BMI < 35 kg/m2 + insulin would have significant occupational implications or weight loss would be beneficial Note: GLP-1 RA should only be continued if a reduction of ≥ 11 mmol/mol (1.0%) in HbA1c + weigh loss of ≥ 3% of initial body weight in 6 months Insulin? Referral or advice from the specialist diabetes team for consideration of treatment with insulin + GLP-1 RA Insulin: Intermediate-acting isophane or Neutral Protamine Hagedorn (NPH) insulin injected once or twice daily according to need NPH insulin + short‑acting insulin (particularly if HbA1c ≥ 75 mmol/mol (9.0%), administered: - separately - pre-mixed (biphasic) human insulin preparation Insulin determir or insulin glargine as alternative to NPH insulin if: - Needs assistance from a carer or healthcare professional to inject insulin - Lifestyle is restricted by recurrent symptomatic hypoglycaemia episodes - Otherwise twice-daily NPH insulin injections in combination with oral antidiabetic drugs would be needed Pre-mixed insulin preparations (including short‑acting insulin analogues, rather than those that include short-acting human insulin preparations) if: - Preference injecting insulin immediately before a meal - Hypoglycaemia is a problem - Blood glucose levels rise markedly after meals Switching from NPH insulin to insulin detemir or insulin glargine if: - Target HbA1c not reached because of significant hypoglycaemia - Significant hypoglycaemia on NPH insulin irrespective of the level of HbA1c reached - Device needed to inject NPH insulin cannot be used, but can administer their own insulin safely and accurately if a switch to one of the long-acting insulin analogues was made - Help from a carer or healthcare professional is needed If on basal insulin regimen (NPH insulin, insulin determir or insulin glargine) monitoring for the need for short-acting insulin before meals (or a pre-mixed insulin preparation)? If on pre-mixed insulin monitoring for the need for a further injection of short-acting insulin before meals or for a change to a basal-bolus regimen with NPH insulin, insulin determir or insulin glargine Drug examples: Biguanide: metformin SU: gliclazide DPP-4i: linagliptin, sitagliptin or vildagliptin Thiazolidinedione (TZD): pioglitazone SGLT2: canagliflozin, dapagliflozin or empagliflozin GLP-1-RA: liraglutide Insulins: Short-acting: - Soluble insulins: insulin (Human Actrapid, Humulin S) - Rapid-acting insulin analogues: insulin lispro (Humalog), insulin aspart (Novorapid) Intermediate-acting: isophane or NPH insulin (Humulin I, Insuman basal, Human Insulatard) Long-acting: insulin glargine U100 (Lantus), insulin detemir (Levemir) Ultra-long acting: insulin degludec (Tresiba), insulin glargine U300 (Toujeo) Advised: - On sources of information and support (eg Diabetes UK) - Lifestyle advice (eg diet, exercise and weight loss if appropriate) - Sexual health - Entitlement to free NHS prescriptions if antidiabetic medication or insulin is used? - Diabetes identification (eg MedicAlert or from Diabetes UK) Resource(s): NICE CKS: Diabetes – type 2 Clinical Effectiveness (CE): Diabetes Mellitus in Adults Information for patient/carer(s): NHS Health A to Z: What is type 2 diabetes Patient UK: Type 2 Diabetes