Type 2 Diabetes Management

The care team and ongoing plan

Short term: relieve acute symptoms. Long term: achieve appropriate glycaemic control via diet and medication; reduce concurrent CV risk factors (smoking cessation, CVD risk assessment, low-dose aspirin in high-risk patients); identify and treat chronic complications; maintain preventive activities (immunisations); referral to the wider care team as needed:

• Diabetes educator — from diagnosis, then as needed for compliance/control issues.
• Dietitian — ideally from diagnosis, then as needed.
• Endocrinologist — type 1 diabetes if not confident managing it; pregnant women with established diabetes or gestational diabetes; uncontrolled hyperglycaemia or significant complications.
• Ophthalmologist/optometrist — dilated fundal exam and cataract check at diagnosis (adults) or puberty (children), then at least every 2 years.
• Podiatrist — from diagnosis, then regularly if peripheral vascular disease, neuropathy, or skin/nail problems are present; refer to a high-risk foot clinic for ulceration or intractable foot pain.
• Pharmacist — medication review, Home Medicines Review.
• Exercise professional — weight management support.
• Dentist — annual check (dental/periodontal disease common in diabetes).

MBS annual cycle of care (item 2517) minimum requirements: BP and BMI at least twice/cycle; foot exam at least twice/cycle; lipids and HbA1c at least twice/cycle; urine albumin/eGFR at least annually; self-care/diet/physical activity review annually; comprehensive eye exam at least every 2 years.

Individual and clinical management goals

Per the RACGP handbook’s “Goals for optimum management” (updated September 2025):

• HbA1c — individualised; generally ≤7% (53 mmol/mol).
• Blood glucose self-monitoring (SMBG) — target 4–7 mmol/L fasting, 5–10 mmol/L postprandial. Recommended for those on sulfonylureas and/or insulin; individualise for others depending on agents used, control, and hypoglycaemia risk; also recommended during intercurrent illness and in pregnancy/gestational diabetes.
• Lipids — statin initiation guided by absolute CVD risk (Australian CVD risk calculator). For secondary prevention: LDL cholesterol <1.4 mmol/L and ≥50% reduction from baseline.
• Blood pressure — individualised; <130/80 mmHg with CKD; 140/90 mmHg a reasonable general target otherwise; lower targets may suit younger patients or those at high stroke risk.
• Urine albumin excretion (uACR) — women <3.5 mg/mmol; men <2.5 mg/mmol.
• Weight — 5–10% weight loss goal if overweight/obese; weight loss ≥10% may allow reduction/cessation of glucose-lowering medication (consider low/very-low-energy meal-replacement diets, pharmacotherapy, or bariatric surgery — see the Australian Obesity Management Algorithm).
• Physical activity — adults: 150 min/week aerobic activity plus 2–3 resistance sessions (≥60 min total); children/adolescents: ≥60 min/day.
• Smoking — zero. Alcohol — ≤10 standard drinks/week, ≤4 on any day.
• Vaccination — influenza, pneumococcus, dTpa, COVID-19, RSV (age >60); consider hepatitis B (if travelling) and herpes zoster.

Pharmacological management

The June 2024 ADS/Diabetes Australia glycaemic management algorithm structures treatment in three tiers, reviewed for HbA1c response every 3 months (consider stopping any agent that hasn’t cut HbA1c by ≥0.5%, weighing glycaemic and non-glycaemic benefits):

1. Monotherapy — metformin is the usual first choice unless contraindicated/not tolerated (a conditional recommendation, not an absolute rule).
2. Dual therapy — add an oral agent or injectable, guided by clinical considerations (CVD, heart failure, CKD, hypoglycaemia risk, obesity), side-effect profile, contraindications and cost. SGLT2 inhibitors and GLP-1 receptor agonists are recommended additions — not reserved for treatment failure — particularly with established or high risk of CVD, heart failure, or CKD, independent of glycaemic control; there is a conditional recommendation against a sulfonylurea being the preferred first add-on, given its hypoglycaemia risk.
3. Multiple therapies — add a further oral agent, GLP-1 RA, or insulin. When adding incretin therapy, use either a DPP-4i or a GLP-1 RA, not both. PBS does not fund GLP-1 RA + SGLT2i together outside specific CKD/heart failure indications. With increasing complexity, consider specialist endocrinology referral.

This replaces the older 2020-era framing (below) in which metformin was positioned as the universal first step before other classes were considered, and SGLT2i/GLP-1 RA were “less commonly used” second/third-line options chosen mainly by cost.

Antihyperglycaemic class and drug	Relative HbA1c lowering	Advantages	Disadvantages
Biguanide — metformin	↓↓	hypoglycaemia unlikely; assists weight loss; improves CV outcomes in overweight patients; extensive experience; low cost	GI adverse effects; vitamin B12 deficiency (screen every 2–5 years); rare lactic acidosis; reduce dose with kidney impairment
Sulfonylureas — gliclazide, glipizide, glibenclamide, glimepiride	↓↓	extensive experience; low cost	weight gain; significant hypoglycaemia especially in older patients (glibenclamide, glimepiride); avoid glibenclamide/glimepiride with kidney impairment — gliclazide and glipizide are preferred if renally impaired
DPP-4 inhibitors — alogliptin, linagliptin, saxagliptin, sitagliptin, vildagliptin	↓ to ↓↓	hypoglycaemia unlikely; no weight gain; improve postprandial control; safe in CVD except saxagliptin/possibly alogliptin	avoid in heart failure (saxagliptin, possibly alogliptin); avoid with pancreatitis history; reduce dose with kidney impairment except linagliptin (no dose adjustment needed — safest DPP-4i in renal impairment)
GLP-1 receptor agonists — dulaglutide, exenatide, liraglutide, semaglutide	↓↓ to ↓↓↓	hypoglycaemia unlikely; weight loss; improve postprandial control; reduce secondary CV events/mortality (liraglutide, semaglutide); slow CKD progression (dulaglutide, liraglutide, semaglutide)	avoid with pancreatitis history or MEN2/medullary thyroid cancer family history (liraglutide); GI adverse effects (often transient); dose adjust/avoid in severe renal impairment (semaglutide/exenatide need eGFR >30; liraglutide/dulaglutide need eGFR >15)
Dual GIP/GLP-1 receptor agonist — tirzepatide	↓↓↓ to ↓↓↓↓	dose-dependent superiority for glycaemic control and weight loss over GLP-1 RA alone, similar GI safety profile; no dose reduction required for renal/hepatic impairment (limited data in severe impairment/ESKD)	same pancreatitis/gallbladder precautions as GLP-1 RAs; caution with diabetic retinopathy (rapid glycaemic improvement can transiently worsen it); avoid in pregnancy
SGLT2 inhibitors — dapagliflozin, empagliflozin, ertugliflozin	↓↓ to ↓↓↓	hypoglycaemia unlikely; weight loss; reduce secondary CV events/mortality; lower BP; slow CKD progression; benefits on heart failure/CKD persist independent of diabetes status	avoid periprocedurally, while fasting, or on very-low-carbohydrate diets; genitourinary infection; reversible creatinine rise; rare volume depletion; uncommon (sometimes euglycaemic) DKA; reduced glycaemic efficacy with kidney impairment — cease at eGFR <30 (heart failure/CKD benefit persists to eGFR ~25)
Insulin	↓↓ to ↓↓↓↓	nearly universal response; theoretically unlimited efficacy; flexible dosing	significant hypoglycaemia; weight gain; parenteral only
Alpha-glucosidase inhibitor — acarbose	↓	hypoglycaemia unlikely; weight neutral; improves postprandial control	GI adverse effects; reduce dose with kidney impairment
Thiazolidinedione — pioglitazone	↓↓	hypoglycaemia unlikely; durable efficacy (protects against progressive beta-cell failure)	weight gain; peripheral oedema; heart failure risk; rare macular oedema/fracture in postmenopausal women; possible bladder cancer risk (pioglitazone); 6–12 weeks to full effect

Practical prescribing notes (from HNE Community HealthPathways)

• eGFR thresholds: metformin — max 2 g/day, consider with careful monitoring down to eGFR 15, cease if acutely unwell with renal risk; SGLT2i — cease below eGFR 30 (cardiorenal benefit persists to ~25); sulfonylureas — gliclazide/glipizide preferred if renally impaired; DPP-4i — linagliptin needs no dose adjustment at any eGFR; GLP-1/GIP RA — semaglutide/exenatide need eGFR >30, liraglutide/dulaglutide/tirzepatide tolerate lower eGFR (tirzepatide has no renal dose adjustment, though evidence in severe impairment/ESKD is limited).
• Perioperative/sick-day SGLT2i cessation: cease 3 days before surgery and during acute illness/dehydration — risk of acute kidney injury and euglycaemic ketoacidosis; educate patients on ketoacidosis symptoms.
• Metformin: start low and titrate (e.g. 500 mg/day, weekly increments); MR formulation reduces GI side effects; screen for B12 deficiency every 2–5 years.

Practical safety pearls — SGLT2i and GLP-1/GIP receptor agonists

• SGLT2 inhibitors — beyond the euglycaemic-DKA and genital-thrush risks above, watch for Fournier’s gangrene (necrotising perineal infection): higher risk in a man with recurrent balanitis/inguinal fungal infection or a woman with recurrent vaginal thrush — cease in these situations. GLP-1 and SGLT2i can be combined when the SGLT2i is for a separate indication (e.g. heart failure).
• GLP-1 / GIP receptor agonists — when adding to insulin, pre-emptively reduce basal insulin ~10% and bolus insulin ~50%, and halve the sulfonylurea to avoid hypoglycaemia. Manage nausea with small low-fat, low-fibre meals, good hydration, and avoiding lying down or drinking with meals. Contraindicated with a personal/family history of medullary thyroid cancer or MEN2. A rare ocular signal (NAION, non-arteritic ischaemic optic neuropathy) is now an established very-rare effect (EMA 2025); defer starting during active diabetic-retinopathy treatment.
• Drug-absorption interactions — GLP-1-induced gastric slowing can impair absorption of thyroxine and the combined oral contraceptive pill; taking these at night mitigates it (and counsel on contraception reliability).
• Reactive (post-prandial) hypoglycaemia is common in insulin-resistant patients after high-GI meals, from delayed insulin release; overnight or fasting hypoglycaemia is more suggestive of an insulinoma.

Starting insulin

Consider insulin once a patient is on maximal oral therapy with suboptimal control (HbA1c/BGL above individualised target), symptomatic or not. It may also be a reasonable alternative for elderly/nursing-home patients with HbA1c >75 mmol/mol (9%), especially if symptomatic hyperglycaemia is difficult to control. Rare adverse effects include congestive heart failure, oedema, lipodystrophy, and allergic reactions; common effects are hypoglycaemia and weight gain. Hypoglycaemia risk factors: inappropriate dose/timing, missed meals, alcohol, exercise, weight loss, concurrent sulfonylureas, or reduced insulin clearance (e.g. renal failure). Basal, premixed, and basal-plus titration follow structured step-wise dose-adjustment protocols based on fasting/postprandial BGL trends — see the RACGP/ADS insulin initiation guides for the detailed titration tables.

Sick-day rules and emergency hyperglycaemia

For routine intercurrent-illness management, see Sick Day Management of T2DM — that page’s “withhold metformin/SGLT2i, continue DPP-4i” framework remains current. Briefly, per RACGP’s more detailed sick-day guidance: commence an action plan when unwell or BGL >15 mmol/L on two consecutive readings; monitor BGL 2–4 hourly; review/temporarily cease metformin, SGLT2i and GLP-1 RA if vomiting, diarrhoea or reduced oral intake; maintain fluid and, where tolerated, usual meal intake.

Red flags for a hyperglycaemic emergency (per the RACGP/ADS joint position statement): persistent capillary BGL >15 mmol/L for more than 8–12 hours (checked 2-hourly), or any BGL >15 mmol/L with symptoms/signs of diabetic ketoacidosis (polyuria/polydipsia, nausea/vomiting, abdominal pain, Kussmaul breathing, ketotic breath, altered consciousness) or hyperosmolar hyperglycaemic state (profound dehydration, altered consciousness) warrants urgent point-of-care blood ketone testing and volume assessment — suspected DKA should be transferred to hospital without delay. Have a high index of suspicion for euglycaemic DKA in SGLT2i users, even with normal or only mildly elevated glucose. Other high-risk groups: insulin pump users, past DKA, pregnancy, elderly patients, corticosteroid/atypical antipsychotic use, and acute infection/sepsis/pancreatitis/MI/trauma/surgery.

Driving

Diabetes and its medications may impair driving ability, mainly through unexpected hypoglycaemia, plus sensory/end-organ complications (vision, peripheral sensation) and comorbidities like sleep apnoea. Drivers with diabetes must meet national medical standards; assessment covers current therapy, commercial vs private licence requirements, control adequacy, hypoglycaemic unawareness, recent severe hypoglycaemic events, and comorbidities/end-organ complications.