Clinician’s Notepad: type 2 diabetes

Log in

Published: 5 July 2021

Clinician’s Notepad: type 2 diabetes

Screening and diagnosis

  • Test HbA1c in people at high risk of type 2 diabetes of any age; the threshold for diagnosis is:
    • HbA1c ≥ 50 mmol/mol
    • HbA1c 41 – 49 mmol/mol classified as “pre-diabetes”


  • Select an appropriate glycaemic target based on patient age, co-morbidities, duration of diabetes, history of hypoglycaemia and overall health status:
    • HbA1c < 48 mmol/mol, appropriate for younger people, e.g. aged < 40 years
    • HbA1c < 53 mmol/mol, appropriate for most people
    • HbA1c 54 – 70 mmol/mol, appropriate if hypoglycaemic risk outweighs benefits of lower target
  • Follow a stepwise treatment progression:
    • Step 1: Lifestyle interventions + metformin (initiate at diagnosis)
    • Step 2: Add a second non-insulin glucose-lowering medicine, i.e. empagliflozin, dulaglutide, vildagliptin, a sulfonylurea or pioglitazone; a third medicine can be added instead of stepping up to insulin
    • Step 3: Add insulin (isophane insulin appropriate for most patients)
    • If HbA1c > 64 mmol/mol at diagnosis, initiate two glucose-lowering medicines; if HbA1c very high, e.g. 80 – 90 mmol/mol, initiate insulin
  • Check adherence to the existing medicine regimen and diet and physical activity approaches before stepping up pharmacological treatment
  • Encourage weight loss at any step to induce remission, slow progression, step down treatment intensity or delay treatment escalation
  • Encourage consumption of low calorie and low GI foods, increase vegetable intake and minimise dietary fat, sugar and alcohol
  • Connect patients to services that can assist with lifestyle changes and provide support
  • Consider referral for bariatric surgery if BMI between 35 – 55 kg/m2 * to assist with weight loss
  • If patients are transitioning from a paediatric service, establish who is responsible for the patient’s diabetes care and ensure they are followed up regularly

* Referral criteria may differ; check with your local DHB

Choosing a Step 2 medicine

  • Consider contraindications, co-morbidities, risk of hypoglycaemia, effects on weight, medicines interactions, adverse effects and eligibility for funding
  • Empagliflozin or dulaglutide are preferred for people with established CVD or at high risk (including Māori and Pacific peoples), or with heart failure or diabetic kidney disease
  • Vildagliptin is preferred for patients who are not eligible for funded empagliflozin or dulaglutide treatment (and are not self-funding treatment)
  • Consider other prescribed medicines and how additional diabetes medicines might affect adherence

Initiating insulin

  • Initiate once-daily basal insulin, injected at night; isophane insulin is appropriate for most patients
  • Determine initial basal insulin dose using body weight:
    • 0.1 units/kg daily if at least one of: HbA1c < 64 mmol/mol, BMI < 18 kg/m2, older age (e.g. aged > 65 years) or frailty, renal or liver failure
    • 0.2 units/kg daily if HbA1c > 64 mmol/mol and BMI > 18 kg/m2
  • Advise patients to begin self-monitoring blood glucose levels once daily before breakfast; goal is blood glucose levels 6 – 8 mmol/L
  • Ensure patients understand how to up-titrate the insulin dose based on fasting blood glucose levels + how to manage hypoglycaemia
  • If treatment intensification required, add bolus insulin to a basal regimen OR initiate a biphasic (premixed) insulin:
    • If starting basal-bolus regimen, add a rapid-acting insulin before largest meal (start with 4 units); increase by 2 units if blood glucose level increase with the meal is > 3 mmol/L on three occasions

Annual review

Standard of care for all people with type 2 diabetes; more frequent review may be indicated.

  • Measure weight, waist circumference (optional), blood pressure
  • Examine feet (including skin, nails, deformity), teeth and gums
  • Request HbA1c, urinary ACR, serum creatinine, LFTs, non-fasting lipid studies
  • Review:
    • Retinal photoscreening up to date
    • CVD risk
    • Smoking status, alcohol intake and recreational drug use
    • Mental health
    • Contraception
    • Cervical, breast and bowel cancer screening up to date
    • Any other associated complications, e.g. sexual dysfunction, recurrent skin or genitourinary infection
There are currently no comments for this article.

Please login to make a comment.

Made with by the bpacnz team

Partner links