Type 2 Diabetes management

DGRefHelp - NHS Dumfries & Galloway
NHS Dumfries and Galloway
Type 2 Diabetes Treatment Pathway (based on NICE 2026)
Rescue treatment (very high glucose / symptomatic hyperglycaemia)
If symptoms of hyperglycaemia (e.g., significant thirst, polyuria, weight loss, fatigue) at any stage:
  • Consider insulin-based treatment or a sulfonylurea (requires access to home blood glucose monitoring and driving advice).
  • Review and step down once blood glucose is within target range and stable.
  • Contact Diabetes Centre for advice
At diagnosis
  • Assess and optimise cardiovascular risk
  • Renal function (eGFR, ACR)
  • Baseline foot assessment
  • Refer to DESMOND
  • Add high priority Code for Type 2 Diabetes which triggers eye screening
  • Consider Diabetes Remission Programme
  • Set treatment goals - HbA1c < 58 is default but higher target may be appropriate (e.g. frailty). Initial aim may be diabetes remission - HbA1c < 48.
Lifestyle (always)
Discuss suitability for Diabetes Remission Programme at every opportunity.
Reinforce diet and behaviour change at every consultation.
Standard treatment pathway
Step 1: Dual therapy
  • Metformin + Dapagliflozin
Tolerance: if standard-release metformin not tolerated, switch to modified-release.
  • Start medication at diagnosis rather than lifestyle changes alone unless patient very motivated
  • Start Metformin 500mg OD and increase by 500mg weekly to 2G daily as tolerated.
  • Once tolerability confirmed add Dapagliflozin 10mg OD - no need to check HbA1c before adding
Step 2: Further intensification (targets not met after 3 months)
Add ONE additional glucose-lowering option, guided by patient priorities and risks:
  • GLP-1 receptor agonist (Semaglutide (Rybelsus)1.5mg, increasing to 4mg after 1 month then 9mg if needed) OR
  • DPP-4 inhibitor (Sitagliptin 100mg) 

Note: GLP-1 - Ensure up to date eye screening. If overdue arrange this before starting. OK to use in background retinopathy.

Step 3: Third line options (targets still not met)
If further treatment is needed, consider stepwise addition (balancing hypoglycaemia risk, weight effects, treatment burden and preference):
  • Sulfonylurea
  • Pioglitazone
Safety: Sulfonylureas (e.g. Gliclazide) require home blood glucose monitoring and DVLA driving advice due to hypoglycaemia risk.
Step 4: Injectable treatment

Injectable GLP-1 receptor agonist if living with obesity (if not already used)

Insulin-based treatment when:
  • HbA1c remains above target despite optimised non-insulin therapy, or
  • symptomatic hyperglycaemia, significant weight loss, or catabolic features, or
  • contraindications/intolerance limit other options.
Where appropriate, consider reducing/withdrawing sulfonylurea when starting insulin to reduce hypoglycaemia risk.
3) Special cases
Atherosclerotic cardiovascular disease
Offer:
  • Metformin AND
  • Dapagliflozin AND
  • Injectible Semaglutide
Early-onset type 2 diabetes - Age < 40 years
  • Lower threshold to add a GLP-1 receptor agonist early.
Chronic kidney disease (very low eGFR)
  • If eGFR <20: consider a DPP-4 inhibitor (Sitagliptin 25mg); if not effective/appropriate, consider pioglitazone or insulin-based treatment.
  • For other CKD stages, follow the renal thresholds in local/NICE guidance.
Frailty / high risk of adverse effects
  • Frailty increases adverse event risk from SGLT-2 inhibitors, consider metformin alone (if tolerated).
  • Consider DPP4 inhibitor (Sitagliptin) as add on.
  • Prioritise the smallest effective number of medicines at the lowest effective dose.
  • Avoid hypoglycaemia-prone options where possible.
Women <50 years – pregnancy planning / risk
  • Ask about pregnancy plans at diagnosis and at every review.
  • Discuss need for tight glycaemic control prior to conception.
  • Early discussion with specialist diabetes team recommended for optimisation of control and medication choice.
  • If pregnancy occurs:
    • Stop all glucose-lowering medication except metformin at confirmation of pregnancy.
    • Urgent referral to specialist diabetes antenatal service.
    • Urgent referral to eye screening team
    • Start insulin promptly under specialist guidance.
    • Provide Libre sensor as per national guidance.
4) Medication review checklist (apply at every review)
Adherence
Check adherence and revisit diet/self-management.
Optimise first
Ensure current doses/formulations are optimised before adding therapy.
SGLT-2i
Consider continuing dapagliflozin for CV/renal benefit even if it provides limited reduction in HbA1c.
GLP-1 / DPP4
Do NOT combine a GLP-1 receptor agonist (e.g. semaglutide)with a DPP-4 inhibitor (e.g. sitagliptin).
Hypoglycaemia risk
If prescribing a sulfonylurea or insulin, ensure access to home blood glucose monitoring and provide driving advice.
Note: This is a simplified summary for quick reference. For full prescribing details and renal thresholds, consult the full NICE NG28 guidance and local formulary.

Diabetes drugs cribsheet

Type 2 Diabetes – Prescribing Tips & Common Pitfalls
Practical guidance for GPs: when each drug is most useful, what to watch for, and common pitfalls.
Core prescribing principles
  • Optimise existing therapy before adding new agents.
  • Match the drug to the patient’s stage of disease, comorbidities and priorities.
  • Minimise hypoglycaemia risk, especially in older or frail patients.
  • Review renal function regularly and adjust therapy accordingly.
  • Avoid unnecessary polypharmacy once cardio-renal benefit is achieved.
Metformin
  • Best value: early disease; foundation therapy.
  • Weight: neutral or modest loss.
  • Hypoglycaemia risk: none alone.
  • Common pitfalls: GI intolerance → switch to modified-release before stopping.
  • Avoid: severe intolerance; acute illness with dehydration/AKI risk (pause temporarily).
  • Renal: review dose if eGFR <45; stop if eGFR <30.
  • Extra notes: B12 deficiency with long-term use (check if neuropathy or anaemia).
SGLT-2 inhibitors (e.g. dapagliflozin)
  • Best value: early–mid disease for cardio-renal protection.
  • Weight: modest loss.
  • Hypoglycaemia risk: low unless combined with insulin/sulfonylurea.
  • Common pitfalls: genital mycotic infections; volume depletion (diuretics); pause during acute illness (“sick day rules”).
  • Avoid: recurrent severe genital infections; significant dehydration/ketosis risk; acute illness with poor intake (pause).
  • Renal: reduced glycaemic effect at low eGFR, cardio-renal benefit may persist; follow local/NICE thresholds for initiation/continuation.
  • Extra notes: counsel on hydration and infection prevention; consider ketone risk in prolonged fasting/acute illness.
DPP-4 inhibitors (e.g. sitagliptin / linagliptin)
  • Best value: later disease or when simplicity/tolerability is key; useful in CKD.
  • Weight: neutral.
  • Hypoglycaemia risk: minimal.
  • Common pitfalls: relatively modest HbA1c reduction; renal dose adjustment needed for most agents.
  • Avoid: do NOT combine with GLP-1 receptor agonists.
  • Renal: sitagliptin needs dose reduction with falling eGFR; linagliptin does not usually need dose adjustment.
  • Extra notes: low side-effect burden; good “safe add-on” where hypoglycaemia is a concern.
GLP-1 receptor agonists (e.g. semaglutide / exenatide)
  • Best value: obesity/weight priority; established ASCVD; early-onset T2D.
  • Weight: significant loss (agent/dose dependent).
  • Hypoglycaemia risk: low alone (higher if used with sulfonylurea/insulin).
  • Common pitfalls: nausea/vomiting—slow titration; stop if no meaningful benefit; dehydration risk in CKD/frailty.
  • Avoid: history of pancreatitis; severe GI disease; severe retinopathy. do not combine with DPP-4 inhibitors.
  • Renal: generally usable but monitor dehydration/AKI risk; exenatide has more renal limitations (see renal table).
  • Extra notes: consider continuing for cardiovascular protection in established ASCVD if tolerated and benefiting overall. Ensure up to date eye screening.
Sulfonylureas (e.g. gliclazide)
  • Best value: rapid glucose lowering; short-term rescue/bridging.
  • Weight: gain.
  • Hypoglycaemia risk: high. Requires access to home blood glucose monitoring and driving advice.
  • Common pitfalls: prolonged hypoglycaemia in older adults; hypos with missed meals.
  • Avoid: frailty/falls risk, irregular eating, high hypo risk occupations, recurrent hypos.
  • Renal: hypoglycaemia risk rises as eGFR falls—use very cautiously at lower eGFR (or avoid).
  • Extra notes: if starting insulin, consider reducing/withdrawing sulfonylurea to reduce hypos.
Pioglitazone
  • Best value: insulin resistance when other options limited.
  • Weight: gain; fluid retention.
  • Hypoglycaemia risk: low alone.
  • Common pitfalls: oedema mistaken for “new heart failure”.
  • Avoid: heart failure; significant oedema; high fracture risk.
  • Renal: not renally cleared (dose not usually adjusted), but fluid retention limits use in CKD/heart failure risk.
  • Extra notes: consider stopping if weight gain/oedema problematic or limited glycaemic benefit.
This page is a practical summary for primary care. For full prescribing details and thresholds, consult NICE NG28 and the local formulary.

Renal impairment prescribing

Renal impairment: prescribing guide (local formulary)
This table reflects local formulary choices and common NICE-consistent thresholds. Always consider eGFR trend, acute illness risk, and frailty.
Drug eGFR ≥45 eGFR 30–44 eGFR 20–29 eGFR <20 Key cautions / notes
Metformin
Metformin MR		 Usual dosing Reduce dose
Max 1 g daily		 Do not initiate; usually stop Stop Switch to MR if GI intolerance. Pause during acute illness, dehydration or AKI risk.
Dapagliflozin Initiate / continue Continue (glycaemic effect reduced) Continue for cardio-renal benefit Do not initiate; stop if advised locally Counsel re genital infections and volume depletion. Apply sick-day rules.
Gliclazide
(incl. MR)		 Use with caution Lower doses only Avoid if possible Avoid High hypoglycaemia risk in CKD and frailty. Avoid long-acting sulfonylureas.
Sitagliptin 100 mg daily 50 mg daily 25 mg daily 25 mg daily Well tolerated. Do NOT combine with GLP-1 receptor agonist.
Linagliptin 5 mg daily 5 mg daily 5 mg daily 5 mg daily Preferred DPP-4 inhibitor in advanced CKD (no dose adjustment).
Pioglitazone Usual dosing Usual dosing Usual dosing Usual dosing Not renally cleared. Avoid in heart failure; causes weight gain and oedema.
Semaglutide
(oral or injectable)		 Usual dosing Usual dosing Use with caution Specialist advice Monitor hydration; pause during vomiting/poor intake. Titrate slowly.
Exenatide Usual dosing Use with caution Avoid Avoid Renally cleared. Higher GI side-effect burden in CKD.
Key point: As eGFR falls, prioritise safety and hypoglycaemia avoidance. DPP-4 inhibitors (especially linagliptin) and insulin are often preferred in advanced CKD.

Stepping down treatment

De-intensification & rationalisation (when to step down)
Use this either when HbA1c is at/near target (reduce treatment burden) or when safety risk outweighs benefit (frailty, recurrent hypoglycaemia, falls risk, renal deterioration, acute illness).
A) If HbA1c at/near target (rationalise therapy)
  • Usually continue metformin if tolerated (weight-neutral, no hypo risk).
  • GLP-1 receptor agonists:
    • Continue if there is meaningful benefit (weight loss and/or improved glycaemic control or CV protection).
    • Stop if there is no meaningful benefit, poor tolerability, or treatment burden outweighs benefit.
  • Never combine a GLP-1 receptor agonist with a DPP-4 inhibitor (if both prescribed, stop the DPP-4 inhibitor).
  • Reduce hypoglycaemia risk first: taper/stop sulfonylurea; consider reducing insulin if safe.
  • Consider stopping weight-gain drugs if benefit is marginal: sulfonylurea, pioglitazone, insulin.
  • Usually continue dapagliflozin for cardio-renal benefit even if HbA1c is controlled (unless contraindicated or not tolerated).
B) If safety risk is high (frailty / hypos / falls / renal decline)
  • Recurrent hypoglycaemia or falls risk: reduce/stop sulfonylurea and/or down-titrate insulin first.
  • Metformin: continue if tolerated; stop only if eGFR <30, significant AKI risk, or severe intolerance.
  • GLP-1 receptor agonists: continue if clearly beneficial and tolerated; consider stopping if:
    • persistent GI intolerance / dehydration risk
    • no meaningful benefit
    • frailty/treatment burden outweighs benefit
  • Avoid pioglitazone if oedema, heart failure risk, or problematic weight gain.
  • Consider a less stringent individualised HbA1c target.
C) Temporary pauses (“sick day” rules)
  • Pause dapagliflozin during acute illness, dehydration, reduced intake, or suspected AKI. Restart when well and eating/drinking normally.
  • Pause metformin during dehydration or AKI risk; restart once well and renal function stable.
  • Pause GLP-1 RA during severe vomiting or poor oral intake (AKI risk).
Principle: metformin and SGLT-2 inhibitors usually form the backbone of treatment; de-intensification should focus first on hypoglycaemia risk, weight gain, and treatment burden.

Editorial Information

Last reviewed: 12/01/2026

Next review date: 12/01/2028

Version: 1.0

Reviewer name(s): Gavin Stephenson.