Type 2 Diabetes Treatment and Management

Authored by , Reviewed by Dr Laurence Knott | Last edited | Meets Patient’s editorial guidelines

This article is for Medical Professionals

Professional Reference articles are designed for health professionals to use. They are written by UK doctors and based on research evidence, UK and European Guidelines. You may find the Type 2 Diabetes (Causes, Symptoms and Treatment) article more useful, or one of our other health articles.


Treatment of almost all medical conditions has been affected by the COVID-19 pandemic. NICE has issued rapid update guidelines in relation to many of these. This guidance is changing frequently. Please visit https://www.nice.org.uk/covid-19 to see if there is temporary guidance issued by NICE in relation to the management of this condition, which may vary from the information given below.

Treatment should be aimed at alleviating symptoms and minimising the risk of long-term complications. Type 2 diabetes is a major risk factor for cardiovascular disease, which is the most common cause of death in people with diabetes. Optimal control of glucose and other cardiovascular risk factors (eg, smoking, sedentary lifestyle, hypertension, dyslipidaemia and obesity) is essential[1].

Management of type 2 diabetes has to be tailored to the individual needs and circumstances of each patient - eg, the benefits of tight glucose control must be weighed against any potential complications such as recurrent hypoglycaemia[2, 3].

  • Structured patient education should be made available to all people with diabetes at the time of initial diagnosis and then as required on an ongoing basis, based on a formal, regular assessment of need.
  • Suitable programmes are the X-PERT Diabetes Programme and the Diabetes Education and Self Management for Ongoing and Newly Diagnosed (DESMOND) Programme. See the separate Diabetes Education and Self-management Programmes article.
  • A study found that a single education and self-management structured programme for people with newly diagnosed type 2 diabetes mellitus did not show any benefit in biomedical or lifestyle outcomes at three years, although there were sustained improvements in some illness beliefs[5].
  • Discuss diet and give dietary advice, taking into account other factors - eg, obesity, hypertension, and renal impairment; offer referral to a dietician.
  • Encourage regular physical activity.
  • Give advice and support on smoking cessation where appropriate.
  • If appropriate, advise of the need to contact DVLA to inform them of the diagnosis - see DVLA Medical Standards of Fitness to Drive[6].
  • Check height and weight and calculate BMI; also measure waist circumference. Waist circumference is significantly associated with the risk of cardiovascular disease[7].
  • Check smoking status and offer cessation advice as appropriate.

See also the separate Diabetes Diet And Exercise article.

  • Emphasise advice on healthy balanced eating. Encourage high-fibre, low-glycaemic-index sources of carbohydrate in the diet, such as fruit, vegetables, whole grains and pulses. Include low-fat dairy products and oily fish, and control the intake of foods containing saturated and trans fatty acids.
  • Integrate dietary advice with a personalised diabetes management plan, including other aspects of lifestyle modification, such as increasing physical activity and losing weight.
  • For adults with type 2 diabetes who are overweight, set an initial body weight loss target of 5% to 10%. Remember that lesser degrees of weight loss may still be of benefit, and that larger degrees of weight loss in the longer term will have advantageous metabolic impact.
  • Advise adults with type 2 diabetes that limited substitution of sucrose-containing foods for other carbohydrate in the meal plan is allowable, but that they should take care to avoid excess energy intake.
  • Discourage the use of foods marketed specifically for people with diabetes.

Be aware that adults with type 2 diabetes who have acute intercurrent illness are at risk of worsening hyperglycaemia. Review treatment as necessary. See also the separate Diabetes and Intercurrent Illness article.

HbA1c measurement and targets

In adults with type 2 diabetes, measure HbA1c levels at:

  • 3- to 6-monthly intervals until the HbA1c is stable on unchanging therapy.
  • 6-monthly intervals once the HbA1c level and blood glucose-lowering therapy are stable.

If HbA1c monitoring is invalid because of disturbed erythrocyte turnover or abnormal haemoglobin type, estimate trends in blood glucose control using one of the following:

  • Plasma glucose profiles.
  • Total glycated haemoglobin estimation (if abnormal haemoglobins).
  • Fructosamine estimation.

Targets
Encourage the person 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.

  • If managed either by lifestyle and diet, or by lifestyle and diet combined with a single drug not associated with hypoglycaemia, support the person to aim for an HbA1c level of 48 mmol/mol (6.5%).
  • For adults on a drug associated with hypoglycaemia, support the person to aim for an HbA1c level of 53 mmol/mol (7.0%).

In adults with type 2 diabetes, if HbA1c levels are not adequately controlled by a single drug and rise to 58 mmol/mol (7.5%) or higher, reinforce advice about diet, lifestyle and adherence to drug treatment, provide support to aim for an HbA1c level of 53 mmol/mol (7.0%), and intensify drug treatment.

Consider relaxing the target HbA1c level on a case-by-case basis, with particular consideration for people who are older or frail, for adults with type 2 diabetes:

  • Who are unlikely to achieve longer-term risk-reduction benefits - for example, people with a reduced life expectancy.
  • For whom tight blood glucose control poses a high risk of the consequences of hypoglycaemia - for example, people who are at risk of falling, people who have impaired awareness of hypoglycaemia, and people who drive or operate machinery as part of their job.
  • For whom intensive management would not be appropriate - for example, people with significant comorbidities.

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.

Self-monitoring of blood glucose

See also the separate Self-monitoring in Diabetes Mellitus article.

Do not routinely offer self-monitoring of blood glucose levels for adults with type 2 diabetes unless:

  • The person is on insulin; or
  • There is evidence of hypoglycaemic episodes; or
  • The person is on oral medication that may increase their risk of hypoglycaemia while driving or operating machinery; or
  • The person is pregnant, or is planning to become pregnant.

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.

If adults with type 2 diabetes are self-monitoring their blood glucose levels, carry out a structured assessment at least annually.

Drug treatment

See also the separate Antihyperglycaemic Agents used for Type 2 Diabetes and Insulin Regimens articles.

Rescue therapy at any phase of treatment
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.

Initial drug treatment
Offer standard-release metformin as the initial drug treatment for adults with type 2 diabetes.
Gradually increase the dose of standard-release metformin over several weeks to minimise the risk of gastrointestinal side-effects in adults with type 2 diabetes.

If an adult with type 2 diabetes experiences gastrointestinal side-effects with standard-release metformin, consider a trial of modified-release metformin.

In adults with type 2 diabetes, review the dose of metformin if the estimated glomerular filtration rate (eGFR) is below 45 ml/minute/1.73m2:

  • Stop metformin if the eGFR is below 30 ml/minute/1.73m2.
  • Prescribe metformin with caution for those at risk of a sudden deterioration in kidney function and those at risk of eGFR falling below 45 ml/minute/1.73m2.

In adults with type 2 diabetes, if metformin is contra-indicated or not tolerated, consider initial drug treatment with:

  • A dipeptidyl peptidase-4 (DPP-4) inhibitor; or
  • Pioglitazone; or
  • A sulfonylurea.

If metformin is contra-indicated or not tolerated, repaglinide is both clinically effective and cost-effective in adults with type 2 diabetes. There is no licensed non-metformin-based combination containing repaglinide that can be offered at first intensification.

Treatment with sodium-glucose cotransporter 2 (SGLT2) inhibitors may be appropriate for some adults with type 2 diabetes if metformin is contra-indicated or not tolerated[8].

First intensification of drug treatment

In adults with type 2 diabetes, if initial drug treatment with metformin has not continued to control HbA1c to below the person's individually agreed threshold for intensification, consider dual therapy with:

  • Metformin and a DPP-4 inhibitor; or
  • Metformin and pioglitazone; or
  • Metformin and a sulfonylurea.

In adults with type 2 diabetes, if metformin is contra-indicated or not tolerated and initial drug treatment has not continued to control HbA1c to below the person's individually agreed threshold for intensification, consider dual therapy with:

  • A DPP-4 inhibitor and pioglitazone; or
  • A DPP-4 inhibitor and a sulfonylurea; or
  • Pioglitazone and a sulfonylurea.

Drugs in dual therapy should be introduced in a stepwise manner, checking for tolerability and effectiveness of each drug.

Treatment with combinations of medicines including SGLT2 inhibitors may be appropriate for some people with type 2 diabetes[9, 10, 11].

Second intensification of drug treatment

In adults with type 2 diabetes, if dual therapy with metformin and another oral drug has not continued to control HbA1c to below the person's individually agreed threshold for intensification, consider either:

  • Triple therapy with:
    • Metformin, a DPP-4 inhibitor and a sulfonylurea; or
    • Metformin, pioglitazone and a sulfonylurea; or
  • Starting insulin-based treatment.

If triple therapy with metformin and two other oral drugs is not effective, not tolerated or is contra-indicated, consider combination therapy with metformin, a sulfonylurea and a glucagon-like peptide-1 (GLP-1) mimetic for adults with type 2 diabetes who:

  • Have a body mass index (BMI) of 35 kg/m2 or higher (adjust accordingly for people from black, Asian and other minority ethnic groups) and specific psychological or other medical problems associated with obesity; or
  • Have a BMI lower than 35 kg/m2 and:
    • For whom insulin therapy would have significant occupational implications; or
    • Weight loss would benefit other significant obesity-related comorbidities.

Only continue GLP-1 mimetic therapy if the person with type 2 diabetes has had a beneficial metabolic response (a reduction of at least 11 mmol/mol [1.0%] in HbA1c and a weight loss of at least 3% of initial body weight in six months).

In adults with type 2 diabetes, if metformin is contra-indicated or not tolerated, and if dual therapy with two oral drugs has not continued to control HbA1c to below the person's individually agreed threshold for intensification, consider insulin-based treatment.

In adults with type 2 diabetes, only offer a GLP-1 mimetic in combination with insulin with specialist care advice and ongoing support from a consultant-led multidisciplinary team.

Treatment with combinations of medicines including SGLT2 inhibitors may be appropriate for some people with type 2 diabetes[9, 10, 11].

Insulin-based treatments

When starting insulin therapy in adults with type 2 diabetes, use a structured programme employing active insulin dose titration that encompasses:

  • Injection technique, including rotating injection sites and avoiding repeated injections at the same point within sites.
  • Continuing telephone support.
  • Self-monitoring.
  • Dose titration to target levels.
  • Dietary understanding.
  • DVLA's Assessing fitness to drive: a guide for medical professionals.
  • Management of hypoglycaemia.
  • Management of acute changes in plasma glucose control.
  • Support from an appropriately trained and experienced healthcare professional.

When starting insulin therapy in adults with type 2 diabetes, continue to offer metformin for people without contra-indications or intolerance. Review the continued need for other blood glucose-lowering therapies.

Start insulin therapy for adults with type 2 diabetes from a choice of a number of insulin types and regimens:

  • Offer NPH insulin injected once or twice daily according to need.
  • Consider starting both NPH and short-acting insulin (particularly if HbA1c is 75 mmol/mol [9.0%] or higher), administered either separately or as a pre-mixed (biphasic) human insulin preparation.

Consider, as an alternative to NPH insulin, using insulin detemir or insulin glargine if:

  • The person needs assistance from a carer or healthcare professional to inject insulin, and use of insulin detemir or insulin glargine would reduce the frequency of injections from twice to once daily; or
  • The person's lifestyle is restricted by recurrent symptomatic hypoglycaemic episodes; or
  • The person would otherwise need twice-daily NPH insulin injections in combination with oral glucose-lowering drugs.

Consider pre-mixed (biphasic) preparations that include short-acting insulin analogues, rather than pre-mixed (biphasic) preparations that include short-acting human insulin preparations, if:

  • A person prefers injecting insulin immediately before a meal; or
  • Hypoglycaemia is a problem; or
  • Blood glucose levels rise markedly after meals.

Consider switching to insulin detemir or insulin glargine from NPH insulin in adults with type 2 diabetes:

  • Who do not reach their target HbA1c because of significant hypoglycaemia; or
  • Who experience significant hypoglycaemia on NPH insulin irrespective of the level of HbA1c reached; or
  • Who cannot use the device needed to inject NPH insulin but who could administer their own insulin safely and accurately if a switch to one of the long-acting insulin analogues was made; or
  • Who need help from a carer or healthcare professional to administer insulin injections and for whom switching to one of the long-acting insulin analogues would reduce the number of daily injections.

Monitor adults with type 2 diabetes who are on a basal insulin regimen (NPH insulin, 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 NPH insulin or insulin detemir or insulin glargine, if blood glucose control remains inadequate.

See also the separate Insulin Regimens article.

See also the separate Diabetes with Hypertension article.

Measure blood pressure at least annually in an adult with type 2 diabetes without previously diagnosed hypertension or renal disease. Measure standing as well as seated blood pressure in people with hypertension and with type 2 diabetes.

Offer and reinforce preventative lifestyle advice.

Salt substitutes containing potassium chloride should not be used by older people, people with diabetes, pregnant women, people with kidney disease and people taking some antihypertensive drugs, such as ACE inhibitors and angiotensin-II receptor blockers.

Discuss starting antihypertensive drug treatment, in addition to lifestyle advice, with adults aged under 80 with persistent stage 1 hypertension who have diabetes. Stage 1 hypertension is defined as clinic blood pressure 140/90 mm Hg to 159/99 mm Hg, and subsequent ABPM daytime average or HBPM average blood pressure ranging from 135/85 mm Hg to 149/94 mm Hg.

  • Offer an ACE inhibitor or an ARB to adults starting step 1 antihypertensive treatment who have type 2 diabetes.
  • If hypertension is not controlled in adults taking step 1 treatment of an ACE inhibitor or ARB, offer the choice of one of the following drugs in addition to step 1 treatment: CCB or a thiazide-like diuretic.
  • If hypertension is not controlled in adults taking step 2 treatment, offer a combination of: an ACE inhibitor or ARB, a CCB and a thiazide-like diuretic. 

Antiplatelet therapy

Do not offer antiplatelet therapy (aspirin or clopidogrel) for type 2 diabetes treatment without cardiovascular disease[4].

Gastroparesis[4]

Consider a diagnosis of gastroparesis in adults with type 2 diabetes with erratic blood glucose control or unexplained gastric bloating or vomiting, taking into account possible alternative diagnoses.

For adults with type 2 diabetes who have vomiting caused by gastroparesis:

  • There is not strong evidence that any available antiemetic therapy is effective.
  • Some people have had benefit with domperidone, erythromycin or metoclopramide.
  • The strongest evidence for effectiveness is for domperidone, but prescribers must take into account its safety profile, in particular its cardiac risk and potential interactions with other medicines.

For treating vomiting caused by gastroparesis in adults with type 2 diabetes:

  • Consider alternating use of erythromycin and metoclopramide.
  • Consider domperidone only in exceptional circumstances (if domperidone is the only effective treatment) and in accordance with MHRA guidance.

If gastroparesis is suspected, consider referral to specialist services if the differential diagnosis is in doubt, or persistent or severe vomiting occurs.

Autonomic neuropathy[4]

Consider the possibility of contributory sympathetic nervous system damage for adults with type 2 diabetes who lose the warning signs of hypoglycaemia.

Consider the possibility of autonomic neuropathy affecting the gut in adults with type 2 diabetes who have unexplained diarrhoea that happens particularly at night.

When using tricyclic drugs and antihypertensive drug treatments in adults with type 2 diabetes who have autonomic neuropathy, be aware of the increased likelihood of side-effects such as orthostatic hypotension.

Investigate the possibility of autonomic neuropathy affecting the bladder in adults with type 2 diabetes who have unexplained bladder-emptying problems.

In managing autonomic neuropathy symptoms, include specific interventions indicated by the manifestations (for example, for abnormal sweating or nocturnal diarrhoea).

See also the separate Autonomic Neuropathy article.

Erectile dysfunction[4]

Offer men with type 2 diabetes the opportunity to discuss erectile dysfunction as part of their annual review. Consider a phosphodiesterase-5 inhibitor to treat problematic erectile dysfunction in men with type 2 diabetes, initially choosing the drug with the lowest acquisition cost and taking into account any contra-indications. Refer men with type 2 diabetes to a service offering other medical, surgical or psychological management of erectile dysfunction if treatment (including a phosphodiesterase-5 inhibitor, as appropriate) has been unsuccessful.

See also the separate Erectile Dysfunction article.

See the separate Assessment of the Patient with Established Diabetes article.

See also the articles on Diabetes Foot, Diabetic Neuropathy, Diabetic Retinopathy and Diabetic Eye ProblemsDiabetic Nephropathy and Diabetic Amyotrophy.

The precise arrangements for referrals will depend on local service provisions and guidelines Most patients with type 2 diabetes can be managed within primary care but referrals such as to podiatry, the multidisciplinary footcare team and the local retinal screening programme, may be required. Referral to a diabetes specialist may be required depending on the development of complications, comorbidity and any difficulties with controlling glucose, lipids or blood pressure.

Refer pregnant women with diabetes, or those planning a pregnancy, for specialist care[13].

This is covered in detail in the separate Prevention of Type 2 Diabetes article.

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Further reading and references

  1. Lorber D; Importance of cardiovascular disease risk management in patients with type 2 diabetes mellitus. Diabetes Metab Syndr Obes. 2014 May 237:169-83. doi: 10.2147/DMSO.S61438. eCollection 2014.

  2. Gerstein HC, Miller ME, Byington RP, et al; Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med. 2008 Jun 12358(24):2545-59. Epub 2008 Jun 6.

  3. Patel A, MacMahon S, Chalmers J, et al; Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. N Engl J Med. 2008 Jun 12358(24):2560-72. Epub 2008 Jun 6.

  4. Type 2 diabetes in adults: management; NICE Guidance (December 2015 - last updated 24th November 2021)

  5. Effectiveness of a diabetes education and self management programme (DESMOND) for people with newly diagnosed type 2 diabetes mellitus: three year follow-up of a cluster randomised controlled trial in primary care; BMJ 2012 344 doi: http://dx.doi.org/10.1136/bmj.e2333

  6. Assessing fitness to drive: guide for medical professionals; Driver and Vehicle Licensing Agency

  7. de Koning L, Merchant AT, Pogue J, et al; Waist circumference and waist-to-hip ratio as predictors of cardiovascular events: meta-regression analysis of prospective studies. Eur Heart J. 2007 Apr28(7):850-6. Epub 2007 Apr 2.

  8. Canagliflozin, dapagliflozin and empagliflozin as monotherapies for treating type 2 diabetes; NICE Technology appraisal (May 2016)

  9. Canagliflozin in combination therapy for treating type 2 diabetes; NICE Technology Appraisal Guidance, June 2014

  10. Dapagliflozin in combination therapy for treating type 2 diabetes; NICE Technology Appraisal Guidance, June 2013 - last updated November 2016

  11. Empagliflozin in combination therapy for treating type 2 diabetes; NICE Technology Appraisal Guidance, Mar 2015

  12. Hypertension in adults: diagnosis and management; NICE (August 2019)

  13. Diabetes in pregnancy - management from preconception to the postnatal period; NICE Clinical Guideline (February 2015 - last updated December 2020)

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