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Management Algorithm For Type 2 Diabetes

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INITIAL MANAGEMENT

Confirm the diagnosis and type of diabetes
Determine individualised glycaemic target

Education, support, healthy eating + exercise
Essential at all times throughout duration of diabetes

Start unless contraindicated
Increase to maximal tolerated dose or 2 g per day

The target HbA1c for most patients with type 2 diabetes is < 53 mmol/mol

IF HIGH RISK of renal or CV disease

Diabetic renal disease* OR heart failure OR known cardiovascular disease OR 5 year CVD risk > 15%

*Renal disease = urinary albumin:creatinine ratio > 3 mg/mmol and/or reduced eGFR
YES
NO
Ensure statin (for all) AND ACEi or ARB (if renal disease or heart failure) AND metformin (if CVD) therapy
Heart failure or renal disease predominates
YES
NO
Add SGLT2i† regardless of HbA1c if no contraindications
(HbA1c needs to be > 53 mmol/mol for funding)
Add GLP1RA† or SGLT2i† regardless of HbA1c if no contraindications. GLP1RA likely preferable if cerebrovascular disease predominates
(HbA1c needs to be > 53 mmol/mol for funding)
If unable to tolerate or HbA1c remains above target
GLP1RA† preferred next therapy after SGLT2i†
SGLT2i† preferred next therapy after GLP1RA†
(dual SGLT2i/GLP1RA therapy is not currently funded)

Alternative agents include:
DPPIVi if not on GLP1RA
Thiazolidinediones (TZD) if no heart failure
Sulfonylureas (SU)
Insulin
If target HbA1c reached
Repeat HbA1c in 3 months
If HbA1c above target
Repeat HbA1c 6 monthly and annual review of CVD + renal risk
If HbA1c above target
  Preferred 2nd line agents 3rd line agents
ADDITIONAL CONSIDERATIONS SGLT2i† GLP1RA† DPPIVi TZD SU Insulin
Risk of hypoglycaemia Rare Rare Rare Rare Yes Yes
Mean ↓ in HbA1c (mmol/mol) 6 - 13 15 5 - 10 15 15 Any
Independent cardiorenal benefits Yes Yes No Yes No No
Effect on weight ↓↓
Funded SA only* SA only† Yes Yes Yes Yes
Escalate therapy + repeat HbA1c every 3 months until target reached
  • May require multiple agents including insulin therapy
  • Ensure adherence to lifestyle management + medications
  • Re-refer for dietitian input if appropriate
  • Repeat HbA1c 6 monthly once target reached
  • Assess CVD and renal risk at least annually
  • Continue standard care to reduce CVD risk e.g. statins, antihypertensives (esp. ACEi in diabetic renal disease) etc.
† SA criteria for SGLT2i and GLP1RA
(all required and same for both classes)
  • Patient has type 2 diabetes with an HbA1c > 53 mmol/mol despite > 3 months of regular use of at least one glucose lowering therapy (includes metformin)
  • The patient is of Māori and/or any Pacific ethnicity OR has known diabetic renal disease OR known CVD OR 5 year CVD risk > 15% OR a high lifetime CVD risk due to onset of diabetes during childhood or as a young adult
  • The patient is not on funded SGLT2i and GLP1RA therapy at the same time