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Page last updated:
26 February 2024
The Type 2 Diabetes formulary guidance is based upon the NICE Type 2 Diabetes in adults: management (NG28) (2015, updated June 2022).
Additional local resources:
Please note: when diagnosing type 2 diabetes if the patient is aged less than 45 years OR BMI is less than 25, consider referral to secondary care for investigation of other aetiology.
For clinical referral guidance for type 2 diabetes, click here.
Involve adults with type 2 diabetes in decisions about their individual HbA1c target. Agree an individualised HbA1c target based on the person's needs and circumstances. Encourage them to achieve the target and maintain it unless any resulting adverse effects (including hypoglycaemia), or their efforts to achieve their target, impair their quality of life. The benefits of tight blood glucose control are not immediate, but accrue over years to decades. It is important to explain this to patients. NICE have produced a patient decision aid which is designed to help individual patients participate in decision making about target HbA1c levels. It summarises information on the things people most often want to think about when they are deciding on what new target HbA1c level is best for them.
The NICE guideline states that a target HbA1c level of 48 mmol/mol is recommended for adult patients with type 2 diabetes managed either by lifestyle and diet, or by lifestyle and diet combined with a single drug not associated with hypoglycaemia. For adults on a drug associated with hypoglycaemia, aim for an HbA1c level of 53 mmol/mol.
If HbA1c levels are not adequately controlled by a single drug and rise to 58 mmol/mol or higher:
Consider relaxing the target HbA1c level on an individual basis, with particular consideration for people who are older or frail that may be unlikely to achieve longer‑term risk‑reduction benefits and perhaps have a reduced life expectancy, or if tight blood glucose control poses a high risk of the consequences of hypoglycaemia, for example patients with increased fall risk, and patients who drive or operate machinery as part of their job. Due consideration should also be given to people who have impaired awareness of hypoglycaemia, and those with significant comorbidities.
Patients diagnosed at a young age (e.g. under 55) should aim for strict NICE targets, unless there are strong reasons not to (such as hypoglycaemic episodes or occupation). Patients with microvascular complications (especially albuminuria or retinopathy) should also normally aim for strict NICE targets. For patients with life expectancy less than 5-10 years or who are vulnerable to hypoglycaemia, it would be reasonable to raise the HbA1c targets by around 10 mmol/mol. Patients with less than 1-2 years life expectancy should be treated primarily for symptom control.
If adults with type 2 diabetes achieve an HbA1c level that is lower than their target and they are not experiencing hypoglycaemia, encourage them to maintain it. Be aware that there are other possible reasons for a low HbA1c level, for example, deteriorating renal function or sudden weight loss.
In adults with type 2 diabetes, measure HbA1c levels at:
Do not routinely offer self-monitoring of blood glucose levels for adults with type 2 diabetes unless the person is on insulin, on oral medication that may increase their risk of hypoglycaemia, is pregnant or planning to become pregnant, or if there is evidence of hypoglycaemic episodes.
Consider short-term self-monitoring of blood glucose levels in adults with type 2 diabetes (and review treatment as necessary), when starting treatment with oral or intravenous corticosteroids or to confirm suspected hypoglycaemia.
Adopt an individualised approach, take into account the patient’s:
Clinicians may offer a 3-6 month trial of lifestyle and diet interventions before commencing drug treatment, although for some patients it may be appropriate to begin treatment with metformin at diagnosis.
NICE guidance [NG28] recommendations on drug treatment are based on the patient’s cardiovascular history or risk of developing cardiovascular disease, renal function (chronic kidney disease) and HbA1c.
Established atherosclerotic cardiovascular disease (NG28 definition)
This includes coronary heart disease, acute coronary syndrome, previous myocardial infarction, stable angina, previous coronary or other revascularisation, cerebrovascular disease (ischaemic stroke and transient ischaemic attack) and peripheral arterial disease.
High risk of developing cardiovascular disease (NG28 definition)
Adults with type 2 diabetes who have:
Optimum cardiovascular risk factor reduction
This should be undertaken alongside intensification of blood glucose lowering therapies. Control of BP, lipids and other lifestyle factors (e.g. smoking cessation) will have a larger impact on risk reduction than tight blood glucose control.
For adults with type 2 diabetes, discuss the benefits and risks of drug treatment, and the options available.
Base the choice of drug treatment(s) on:
At each point, think about and discuss the following with the person:
Intensification of therapy:
If an adult with type 2 diabetes is symptomatically hyperglycaemic, consider insulin or a sulfonylurea, and review treatment when blood glucose control has been achieved.
Click here for NICE NG28 visual summary
If HbA1c rises above 48mmol/mol after 3-6 months of diet and lifestyle intervention, commence treatment.
Assess the patient for the following conditions before starting treatment.
Start treatment with metformin standard-release (see Antidiabetic drugs for dose titration). If not tolerated, switch to metformin modified-release.
When metformin tolerability is established, dual therapy may be commenced:
If metformin is not appropriate or not tolerated and the patient has:
If new cardiovascular disease or CHF, a SGLT2 inhibitor is recommended, either:
Consider a SGLT2 inhibitor if no established disease but risk of cardiovascular disease has increased.
Dapagliflozin or empagliflozin are also recommended as an add-on to an ACE inhibitor or ARB for CKD in patients with type 2 diabetes. For criteria for initiation of ACE inhibitors or ARBs and dapagliflozin or empagliflozin for CKD, refer to the dapagliflozin and empagliflozin entries.
OR
Insulin-based treatment (go to ‘Commencing insulin in type 2 diabetes’ below)
GLP-1 mimetics and tirzepatide: If triple oral therapy (with metformin) is not sufficiently effective, not tolerated or contraindicated
GLP-1 mimetic shortage (National Patient Safety Alert 3rd January 2024): For more information, refer to Antidiabetic drugs.
Continue metformin and replace one of the other oral drugs with a GLP 1 mimetic* or tirzepatide for patients who:
Do not combine:
*Continuation of a GLP-1 mimetic
Only continue GLP-1 mimetic therapy if the adult with type 2 diabetes has had:
When starting insulin, use a structured programme and continue to offer metformin for people without contraindications or intolerance. Review the continued need for other blood glucose lowering therapies.
Canagliflozin, dapagliflozin or empagliflozin in combination with insulin with or without other antidiabetic drugs may be recommended as an option for treating type 2 diabetes.
Only offer insulin and a GLP-1 mimetic with specialist care advice and ongoing support from a consultant-led multidisciplinary team.
Start insulin therapy for adults with type 2 diabetes from a choice of a number of insulin types and regimens:
Consider switching to insulin detemir or insulin glargine from isophane insulin (NPH) in adults with type 2 diabetes:
Monitor adults with type 2 diabetes for the need to change the regimen.
Monitor adults with type 2 diabetes who are on a basal insulin regimen (Isophane insulin [NPH], insulin detemir or insulin glargine) for the need for short-acting insulin before meals (or a pre-mixed [biphasic] insulin preparation).
Monitor adults with type 2 diabetes who are on pre-mixed (biphasic) insulin for the need for a further injection of short-acting insulin before meals or for a change to a basal bolus regimen with isophane insulin (NPH) or insulin detemir or insulin glargine, if blood glucose control remains inadequate.
NICE have produced a patient decision aid aimed at helping adults with type 2 diabetes think about their options for controlling their blood glucose to try to reduce the long-term risks of diabetes. The decision aid is intended to help adults with type 2 diabetes at the first intensification of drug treatment. It is not intended for use at other stages in the care pathway, or for women with type 2 diabetes who are pregnant or planning to become pregnant. It summarises information on the things people most often want to think about and discuss with their healthcare team when they are deciding on what new target HbA1c level is best for them, and which medicines they might try to achieve this target.
Do not offer antiplatelet therapy (aspirin or clopidogrel) for adults with type 2 diabetes without CVD
All patients with diabetes and a history of CVD should receive antiplatelet therapy (see section 2.9 Antiplatelet drugs).
Patients with Type 2 diabetes should have their lipids managed in line with the advice in Chapter 2 of the formulary.
Patients with Type 2 diabetes should have hypertension managed in line with the advice provided in Chapter 2 of the formulary.