Updated Guidelines 2026:
NICE NG28 was updated on 18 February 2026. Most adults with newly diagnosed type 2 diabetes should now be offered modified-release metformin plus an SGLT-2 inhibitor from the start (introduced one at a time). People with atherosclerotic cardiovascular disease should also be offered subcutaneous semaglutide (up to 1 mg weekly). People diagnosed before age 40 can be considered for a GLP-1 receptor agonist or tirzepatide early. The old "metformin alone, then add something" approach has gone — the pathway now depends on comorbidity (heart failure, atherosclerotic CVD, CKD, frailty, early onset, obesity).
Also act now: Levemir® (insulin detemir) is being discontinued. NHS England (22 June 2026) asks that all remaining patients are switched to an alternative basal insulin by 30 November 2026; do not start anyone new on it.
Diabetes for GPs: Your Essential Guide
No sugar-coating here — just the new “flozin-first” world, served with slow-release metformin
☕ Tea-Friendly Learning⏰ For GP Trainees Short on Time🚩 Red Flag Focused
Last Updated: 19 September 2026
Executive Summary: What You’ll Master Today
Because you have 47 other things to do before lunch, and that’s just the morning list
What This Page Covers:
Quick Facts at a Glance:
4.7 millionUK people with diagnosed diabetes
1.3 millionLiving with undiagnosed type 2
1 in 216–44s with type 2 are undiagnosed
17,000Deaths NICE 2026 changes could prevent
Sources: Diabetes UK (2024–25 registrations; undiagnosed estimate); ONS analysis via Diabetes UK (Feb 2024); NICE news release 18 Feb 2026 (UK, over 3 years).
📥 Downloads
path: DIABETES
- Diabetes and Renal Disease — Bradford VTS Teaching Deck.pptx
- Diabetes During Ramadan.pptx
- Diabetes in 10 Steps.pptx
- Diabetes in Primary Care - the basics.pptx
- Diabetes — Sick Day Rules, SADMAN & Emergencies.pptx
- Drugs Algorithm in Type 2 by Trend.pdf
- Drugs in Type 2 Diabetes - a detailed.pdf
- Drugs in Type 2 Diabetes - a formulary.docx
- Drugs in Type 2 Diabetes - NICE algorithm.docx
- HbA1c and DCCT explained.docx
- Home Glucose Monitoring - guidelines.docx
- Insulin Formulary - for type 1 and type 2 - detailed.pdf
- Insulin Formulary - for type 1 and type 2.docx
- Language Matters - switch small things you say.pdf
- Language Matters - talking about diabetes.pptx
- Prediabetes.pptx
- Ramadan and Type 2 diabetes Patient Handout.pdf
- Ramadan and Type 2 diabetes Patient Leaflet.pdf
- Steroid Induced Hyperglycaemia & Diabetic Gastroparesis.pptx
🌐 Web Resources
- NICE NG28 — Type 2 diabetes in adults (Feb 2026)
The primary guideline: comorbidity-based medicine pathway, targets, sick day rules.
- NICE CKS — Diabetes type 2
Practical primary care summary: diagnosis, management and prescribing.
- BNF (NICE)
Always check doses, renal adjustments and interactions before prescribing.
- PCDO Society
Primary care diabetes & obesity society: how-to guides, e-learning, conference.
- Diabetes & Primary Care (DiabetesontheNet)
Free UK primary care journal — excellent NG28 2026 factsheets.
- TREND Diabetes
Free patient leaflets: sick day rules, hypos, insulin, driving.
- DVLA — Diabetes and driving
Who must notify, glucose checks before driving, hypo rules.
- NHS Type 2 Path to Remission Programme
Low-calorie diet programme referenced by NICE NG28.
- NHS England — Language Matters
Non-judgemental words for diabetes conversations (endorsed by NG28).
- QRISK3 calculator
10-year CVD risk for statin decisions in type 2 diabetes.
- Kidney Failure Risk Equation (UK)
5-year kidney failure risk — NICE NG203 referral threshold is >5%.
- National Diabetes Audit
Benchmark your care processes and treatment targets.
📚 Quick Navigation
🧠 Brainy Bites🧬 Understanding Diabetes🔬 Diagnosis & Investigations📊 Monitoring & HbA1c Targets⚠️ Complications🥗 Lifestyle & Remission💊 Medicines: NICE 2026 Pathway🛡️ Heart & Kidney Protection🚨 Acute Emergencies🤒 Sick Day Rules📋 Annual Review🚗 Driving & Travel🤰 Diabetes & Pregnancy🌙 Ramadan & Fasting💪 You've Got This
💡
CHAFE-O: the 6 questions that pick your pathway — Before prescribing, ask: CKD (what is the eGFR?), Heart failure?, Atherosclerotic CVD?, Frailty?, Early onset (under 40)?, Obesity? NICE 2026 now chooses medicines by comorbidity, not by a single ladder. If more than one applies, decide with the patient which to prioritise.
🎯
Two tablets, one at a time — Start MR metformin, titrate, then add the flozin once metformin is at the maximum tolerated dose. You might say: “We’ll start one tablet first and add the second when your tummy has settled — the second one also protects your heart and kidneys.”
⚠️
Unwell on a flozin? Check ketones, not just sugar — SGLT-2 inhibitors can cause DKA with near-normal glucose. Vomiting, abdominal pain or breathlessness on a flozin = check ketones and think DKA until proven otherwise.
💊
A “perfect” HbA1c on gliclazide or insulin is a question, not a trophy — An HbA1c well below 53 in someone on a hypo-causing drug should make you ask about hypos. NICE also reminds us a falling HbA1c can mean worsening kidneys or weight loss.
🩺
Adult does not automatically mean type 2 — Slim, rapid onset, weight loss, ketones, or poor response to tablets? Think type 1 or LADA (slow-onset autoimmune diabetes). NICE 2026 explicitly says to revisit the diagnosis if the response to medicines doesn’t fit.
📋
Pause, don’t abandon — Sick day rules must include how to restart. NICE’s committee saw many people whose metformin or flozin was stopped during an illness and simply never restarted.
🗣️
Words matter — Swap “Are you compliant?” for “How are you getting on with your tablets? Lots of people find them tricky.” NG28 now points to NHS England’s Language Matters guide.
⏰
Levemir countdown — Search your list for insulin detemir now. All switches to an alternative basal insulin should be done by 30 November 2026, usually with a 10–20% dose reduction and closer glucose monitoring — follow ABCD/PCDO switching guidance.
📘 What is it? A group of conditions with chronic hyperglycaemia caused by defects in insulin secretion, insulin action, or both. In practice, your first job is to get the type right — because it changes everything that follows.
🧠 Mnemonic: The 4 Ts — classic symptoms (Diabetes UK awareness campaign for type 1)
T
Toilet — passing urine more often, bed-wetting, nocturia
T
Thirsty — unable to quench thirst
T
Tired — more tired than usual
T
Thinner — weight loss despite eating
The Types of Diabetes
Tap each type to expand
- Cause: autoimmune destruction of pancreatic beta cells → absolute insulin deficiency.
- Share: about 8% of people with diagnosed diabetes in the UK Source: Diabetes UK
- Clues: often (not always) younger and slim; rapid onset over days–weeks; weight loss; ketones.
- Can start at any age — adult-onset type 1 is commonly mislabelled as type 2.
- Associated autoimmunity: thyroid disease and coeliac disease.
- Management: lifelong insulin (specialist-led), structured education (e.g. DAFNE), CGM for all adults (NG17), hybrid closed loop for some (TA943).
- Cause: insulin resistance plus progressive beta-cell failure.
- Share: about 90% of people with diagnosed diabetes Source: Diabetes UK
- Risk factors: overweight/central obesity, family history, South Asian, Chinese, Black African and African-Caribbean heritage (2–4 times higher risk), previous gestational diabetes, PCOS, hypertension, CVD, antipsychotics/steroids.
- Presentation: often silent — found on screening, or with thrush, UTIs, tiredness or blurred vision.
- Early onset: NICE defines early-onset type 2 as diagnosed before age 40; these patients carry a very high lifetime cardiovascular and renal risk.
- Management: lifestyle, remission programmes, and the NICE 2026 comorbidity-based medicine pathway (Section 6).
- Definition: hyperglycaemia first recognised in pregnancy.
- Diagnosis (75 g OGTT): fasting ≥5.6 mmol/L or 2-hour ≥7.8 mmol/L Source: NICE NG3
- After birth: fasting plasma glucose at 6–13 weeks (or HbA1c after 13 weeks), then HbA1c yearly — see Section 12.
- Why it matters: high lifelong risk of type 2 diabetes and of GDM in future pregnancies.
- What: Latent Autoimmune Diabetes in Adults — slow-burning type 1.
- Suspect if: not overweight, rapid loss of control on tablets, weight loss, personal/family autoimmunity.
- Tests: GAD antibodies, C-peptide (via specialist advice).
- Why it matters: these patients will need insulin; SGLT-2 inhibitors carry a higher DKA risk if there is insulin deficiency.
- What: Maturity Onset Diabetes of the Young — single-gene diabetes, autosomal dominant.
- Suspect if: diagnosed young (often <25), strong family history over generations, antibody-negative, not typical type 1 or 2.
- Why it matters: some subtypes respond to low-dose sulfonylurea; some need no treatment. Genetic testing via specialist.
- Pancreatic (“type 3c”): chronic pancreatitis, pancreatic cancer, pancreatectomy, cystic fibrosis, haemochromatosis.
- Endocrine: Cushing’s, acromegaly, phaeochromocytoma, hyperthyroidism.
- Drug-induced: corticosteroids, antipsychotics (e.g. olanzapine, clozapine), thiazides.
🧠 Mnemonic: PANCREAS — causes of secondary diabetes
P
Pancreatitis — chronic pancreatitis damages islet cells
A
Acromegaly — growth hormone antagonises insulin
N
Neoplasm — pancreatic cancer — new diabetes can be the first sign
C
Cushing’s & corticosteroids — endogenous or prescribed steroids
R
Removal — pancreatectomy
E
Endocrine others — phaeochromocytoma, hyperthyroidism
A
Antipsychotics & other drugs — olanzapine, clozapine, thiazides
S
Storage & sticky secretions — haemochromatosis and cystic fibrosis
🚩 Red Flags — Do Not Miss
🚩
Age 60+ with weight loss and new-onset diabetes — consider an urgent direct-access CT (within 2 weeks) to look for pancreatic cancer (NICE NG12)
🚩
New diabetes with ketones, vomiting or drowsiness — same-day hospital assessment for DKA
🚩
Slim adult with rapid-onset hyperglycaemia — seek same-day specialist advice — do not assume type 2
🃏 Flip-card check: which type?
Diagnosing Diabetes
Work through the tabs in order
Symptoms to ask about
- Thirst, passing urine often, nocturia
- Unexplained weight loss
- Tiredness, blurred vision
- Recurrent thrush, UTIs, skin infections
- Slow-healing wounds
- Tingling or numb feet
Risk factors to record
- Age 40+ (25+ in higher-risk ethnic groups)
- BMI ≥25 (≥23 South Asian/Chinese)
- First-degree relative with diabetes
- South Asian, Chinese, Black African, African-Caribbean heritage
- Previous gestational diabetes, PCOS
- Hypertension, CVD, stroke
- Severe mental illness, learning disability
- Steroids, antipsychotics
✅ Patient script: “Some of your symptoms can happen when blood sugar runs high. A simple blood test will tell us — and if it is diabetes, catching it early really does protect your eyes, kidneys and heart.”
General
- Weight, BMI, waist circumference
- Blood pressure
- Hydration; breath ketones if unwell
- Acanthosis nigricans (dark velvety skin in skin folds = insulin resistance)
Feet & vascular
- Inspect skin, calluses, ulcers, deformity
- Pulses (dorsalis pedis, posterior tibial)
- 10 g monofilament sensation
- Signs of infection or ischaemia
| Test | Normal | Non-diabetic hyperglycaemia | Diabetes |
|---|---|---|---|
| HbA1c | <42 mmol/mol | 42–47 mmol/mol | ≥48 mmol/mol |
| Fasting plasma glucose | <5.5 mmol/L | 5.5–6.9 mmol/L | ≥7.0 mmol/L |
| Random plasma glucose | — | — | ≥11.1 mmol/L with symptoms |
| 75 g OGTT (2-hour) | <7.8 mmol/L | 7.8–11.0 (impaired glucose tolerance) | ≥11.1 mmol/L |
Sources: WHO criteria as used by NICE CKS/Diabetes UK; non-diabetic hyperglycaemia ranges from NICE PH38.
🛑 Symptomatic vs asymptomatic: With symptoms: one diagnostic result is enough. Without symptoms: repeat the test (ideally the same test) on a separate day; both must be in the diabetic range. If discordant, go with the lower result and monitor. Never diagnose on urine glucose or a finger-prick alone.Source: Diabetes UK / NICE CKS
🧪 Always dip for ketones: Ketones in a new diagnosis point towards type 1 or DKA — act the same day.
HbA1c may mislead in:
- Suspected type 1 (any age), children and young people, short symptom history
- Acutely unwell people at high risk
- Pregnancy
- Haemoglobinopathies (e.g. sickle cell, thalassaemia trait), haemolytic anaemia, recent blood loss or transfusion
- Advanced CKD (stages 4–5)
- Rapid glucose rise from drugs (e.g. steroids, antipsychotics) or acute pancreatic damage
📘 What NICE says to use instead: If HbA1c is invalid because of disturbed red cell turnover or abnormal haemoglobin, use quality-controlled plasma glucose profiles, total glycated haemoglobin, or fructosamine.Source: NICE NG28 1.5.3
Who should be risk-assessed (NICE PH38):
- All adults aged 40 and over (not pregnant)
- Adults aged 25–39 of South Asian, Chinese, African-Caribbean, Black African or other high-risk ethnic background
- Anyone with a condition that raises risk: CVD, hypertension, obesity, stroke, PCOS, previous GDM, severe mental illness, learning disability
✅ Two-stage approach: Stage 1: validated risk score (e.g. Diabetes UK “Know Your Risk”). Stage 2: fasting glucose or HbA1c for those at high risk. Consider a blood test for anyone 25+ of South Asian or Chinese descent with BMI >23. Reassess at 5 years if low risk, 3 years if moderate risk, at least yearly if high risk (e.g. HbA1c 42–47).Source: NICE PH38
⚠️ Non-diabetic hyperglycaemia (HbA1c 42–47): Code it, refer to the NHS Diabetes Prevention Programme, give weight/activity advice and recheck HbA1c at least yearly.
🚩 Refer Urgently
🚩
Vomiting, abdominal pain, drowsiness, heavy ketones or dehydration — same-day hospital admission (possible DKA/HHS)
🚩
Suspected type 1 in an adult — same-day specialist advice
🚩
Pregnant (or planning pregnancy) with diabetes — urgent referral to the joint diabetes–antenatal team
New diagnosis checklist:
- Confirm the type (think LADA, MODY, type 3c)
- Code diabetes type; add to register and set recall
- Refer immediately to the local diabetic eye screening serviceSource: NICE NG28 1.43.1
- Offer structured education (e.g. DESMOND) at diagnosisSource: NICE NG28 1.2.1
- Baseline: HbA1c, U&E/eGFR, urine ACR, lipids, BP, BMI, foot risk, smoking, QRISK3
- Consider the NHS Type 2 Diabetes Path to Remission Programme
- Assess CHAFE-O comorbidities before choosing medicines (Section 6)
🔀 Is it diabetes?
START: Raised glucose or HbA1c result
↓
❓ Symptoms of hyperglycaemia (or unwell)?
YES ↓NO ↓
One diagnostic result confirms. Dip ketones today; if ketones/unwell → same-day hospital.
Repeat the test on another day. Two results ≥ threshold = diabetes.
↓
HbA1c 42–47: non-diabetic hyperglycaemia → NHS Diabetes Prevention Programme + yearly HbA1c
⚠️ Targets are agreed, not imposed: NICE asks you to discuss and agree an individual HbA1c target, and to stop chasing it if the effort or hypos damage quality of life.
HbA1c Targets
Type 2 (NICE NG28) and frailty (UK consensus)
| Situation (type 2) | HbA1c target | What NICE says |
|---|---|---|
| Lifestyle/diet, or medicines not causing hypos (e.g. metformin, SGLT-2, DPP-4, GLP-1) | 48 mmol/mol (6.5%) | Support the person to aim for this |
| Any medicine that can cause hypos (sulfonylurea, insulin) | 53 mmol/mol (7.0%) | Tighter targets risk hypoglycaemia |
| HbA1c rises to 58 mmol/mol (7.5%) or higher | Aim for 53 mmol/mol | Reinforce lifestyle & adherence, then intensify medicines |
| Older, frail, reduced life expectancy, high hypo risk (falls, impaired awareness, drives for work) | Relaxed — agreed individually | Use the NICE patient decision aid |
Source: NICE NG28 recommendations 1.5.7–1.5.9 (2015, amended 2026). Type 1: aim for HbA1c 48 mmol/mol or lower (NICE NG17), individualised to avoid problematic hypos.
| Frailty level | De-escalate if HbA1c below | Target |
|---|---|---|
| Fit older person | 53 mmol/mol | 58 mmol/mol (7.5%) |
| Moderate to severe frailty | 58 mmol/mol | 64 mmol/mol (8.0%) |
| Very severe frailty | 64 mmol/mol | 70 mmol/mol (8.5%) |
Not NICE: UK expert consensus (Strain et al, Diabetic Medicine 2018), widely used in UK primary care. Use the Rockwood Clinical Frailty Scale.
✅ Deprescribing is good medicine: If HbA1c falls below the de-escalation threshold in a frail person, reduce or stop sulfonylureas/insulin first. Document the relaxed target clearly.
- HbA1c: every 3–6 months until stable on unchanging therapy, then every 6 monthsSource: NICE NG28 1.5.1
- Capillary self-monitoring (type 2): not routine unless on insulin, having hypos, on a hypo-causing tablet and driving/operating machinery, or pregnant/planning pregnancySource: NICE NG28 1.6.2
- Short-term finger-pricks: consider when starting oral/IV steroids, or to confirm suspected hyposSource: NICE NG28 1.6.3
- Unexplained mismatch between HbA1c and glucose readings → seek diabetes or biochemistry advice.
🛑 Low HbA1c on a sulfonylurea or insulin: Phone the patient and ask about hypos. A “normal” HbA1c here is not a win. Also remember NICE’s warning: a falling HbA1c can reflect deteriorating kidney function or sudden weight loss.Source: NICE NG28 1.5.10
Continuous Glucose Monitoring (CGM)
Who gets a sensor?
- Offer all adults with type 1 a choice of real-time CGM or intermittently scanned CGM (“flash”)Source: NICE NG17
- Hybrid closed loop (pump + sensor + algorithm): adults with HbA1c ≥58 mmol/mol or disabling hypoglycaemia despite pump or CGM; also pregnant/planning pregnancy; rolled out over 5 yearsSource: NICE TA943
- Capillary targets (type 1): waking 5–7; before meals 4–7; at least 90 min after meals 5–9 mmol/LSource: NICE NG17
- Time in range = % of time spent at 3.9–10 mmol/L; review it alongside HbA1c.
- Offer isCGM (flash) to adults with type 2 on multiple daily insulin injections if any of: recurrent or severe hypos; impaired hypo awareness; a condition/disability preventing finger-prick testing; or would otherwise need 8+ tests a day
- Also offer isCGM if insulin-treated and a carer/healthcare professional would otherwise monitor glucose
- rtCGM is an alternative if the same or lower cost
- People on CGM still need finger-prick strips for checks and back-upSource: NICE NG28 1.7.1–1.7.5
📘 GP role with CGM: CGM is started by a team with expertise in its use. Your job: continue prescriptions where locally agreed, look at the data at reviews, and ask about problems using the device.Source: NICE NG28 1.7.4, 1.7.8–1.7.9
🧠 Mnemonic: EKNF-H — the big five complication checks
E
Eyes — screening programme; emergency signs below
K
Kidneys — eGFR + urine ACR every year
N
Nerves — monofilament, symptoms, autonomic clues
F
Feet — risk-stratify and refer by risk
H
Heart — QRISK3, statin, BP, smoking
Complications in Detail
Expand each topic
- Refer to the NHS Diabetic Eye Screening Programme immediately at diagnosis; screening then per programme scheduleSource: NICE NG28 1.43.1
- Refer to ophthalmology according to NHS Diabetic Eye Screening pathway standards.
- Rapid HbA1c reduction can temporarily worsen retinopathy — NICE NG28 points to the diabetic retinopathy guideline when starting glucose-lowering treatment.
🚩 Red Flags — Do Not Miss
🚩
Sudden loss of vision — emergency ophthalmology review
🚩
Rubeosis iridis (new vessels on the iris) — emergency ophthalmology review
🚩
Pre-retinal or vitreous haemorrhage — emergency ophthalmology review
🚩
Retinal detachment — emergency ophthalmology review
- Check eGFR and urine ACR at least annually. Confirm an ACR of 3 mg/mmol or more on a repeat sample (no repeat needed if the first is 70 or more).
- ACR ≥3 mg/mmol: offer an ACE inhibitor or ARB, titrated to the highest licensed dose toleratedSource: NICE NG203
- Add an SGLT-2 inhibitor (on an optimised ACE-i/ARB): offer if ACR >30; consider if ACR 3–30 (if within licence/eGFR thresholds)Source: NICE NG203
- BP target with an abnormal ACR: below 130/80 mmHgSource: NICE NG203
- Accept an eGFR fall of up to 25% (or creatinine rise up to 30%) after starting ACE-i/ARB; do not start if potassium >5.0, stop if >6.0.
💊 Kidney-protection prescribing
| Drug | Role | Start | Titrate / maximum | Notes |
|---|---|---|---|---|
| Ramipril | ACE inhibitor — 1st line | Diabetes + microalbuminuria: 1.25 mg once daily | Double every 2 weeks to 2.5 mg then 5 mg (renal indication). Hypertension/CV prevention: max 10 mg daily | Check U&E and creatinine 1–2 weeks after starting/any increase |
| Losartan | ARB — 2nd line (e.g. ACE-i cough) | 50 mg once daily | May increase to 100 mg once daily after 1 month | Consider an ARB first in people of Black African or African-Caribbean family origin |
| Dapagliflozin | SGLT-2 inhibitor add-on | 10 mg once daily | Fixed dose | Avoid initiation if eGFR <25 (CKD indication) |
| Empagliflozin | SGLT-2 alternative | 10 mg once daily | Fixed dose for CKD | Avoid initiation if eGFR <20 (CKD indication) |
Sources: UK SmPCs (ramipril, losartan); NHS South West London ICB SGLT-2i CKD guidance. Never combine an ACE inhibitor with an ARB. Duration: long term, reviewed at least annually.
Refer to renal (NICE NG203) if:
- 5-year kidney failure risk >5% on the UK Kidney Failure Risk Equation
- ACR 70 mg/mmol or more, unless known to be due to diabetes and already appropriately treated
- ACR >30 with haematuria
- Sustained eGFR fall of 25% or more with a change in category within 12 months, or a fall of 15 mL/min/1.73m² or more per year
- Hypertension uncontrolled on 4 medicines; suspected rare/genetic causes or renal artery stenosis
- Screen yearly: 10 g monofilament, vibration sense, symptoms (burning, tingling, numbness).
- Painful neuropathy: offer a choice of amitriptyline, duloxetine, gabapentin or pregabalinSource: NICE NG173
- Autonomic neuropathy: think about it in lost hypo awareness, unexplained night-time diarrhoea, bladder-emptying problems, postural hypotensionSource: NICE NG28 1.40
- Gastroparesis: erratic glucose, bloating or vomiting; consider alternating erythromycin (off-label) and metoclopramide; domperidone only in exceptional circumstances per MHRA; refer if diagnosis unclear or vomiting persistentSource: NICE NG28 1.38
- Erectile dysfunction: offer to discuss at annual review; consider a PDE-5 inhibitor, choosing the one with the lowest acquisition costSource: NICE NG28 1.42
💊 Painful diabetic neuropathy
| Drug | Start | Titrate / maximum | Trial length | Key cautions |
|---|---|---|---|---|
| Duloxetine (SNRI) | 60 mg once daily | Max 120 mg daily in divided doses | Review at ~8 weeks | Avoid in severe renal impairment; taper when stopping |
| Amitriptyline (off-label) | 10 mg at night | Increase gradually; max 75 mg daily in primary care (higher only with specialist) | Review at ~6–8 weeks | Sedation, falls, anticholinergic burden, cardiac disease, glaucoma |
| Pregabalin (Schedule 3 CD) | 150 mg/day in 2 divided doses (lower if frail/renal) | Up to max 600 mg/day in 2 divided doses | Stop if no benefit 8 weeks after reaching max tolerated dose | Dependence/misuse; reduce dose in renal impairment |
| Gabapentin (Schedule 3 CD) | 300 mg once on day 1, twice on day 2, three times on day 3 | Titrate to effect; max 3.6 g/day in 3 divided doses | As above | Dependence/misuse; reduce dose in renal impairment |
Sources: NICE NG173 / NICE CKS neuropathic pain (choice of any one of the four first; if ineffective or not tolerated, switch to another of the four); gabapentin titration per UK SmPC. Do not combine gabapentin with pregabalin.
| Risk | Features | Action |
|---|---|---|
| Low | No risk factors present except callus alone | Annual assessment; foot-care education; explain they could move to a higher risk group |
| Moderate | Deformity or neuropathy or non-critical limb ischaemia | Refer to Foot Protection Service (first assessment within 6–8 weeks; reviews every 3–6 months) |
| High | Previous ulcer or amputation; on renal replacement therapy; neuropathy + non-critical ischaemia; neuropathy or ischaemia with callus and/or deformity | Refer to Foot Protection Service (first assessment within 2–4 weeks); more frequent review |
| Active | Ulceration, spreading infection, critical limb ischaemia, gangrene, suspected acute Charcot, or unexplained hot, red, swollen foot | Refer within 1 working day to the MDT foot service/Foot Protection Service for triage within 1 further working day |
Source: NICE NG19 (risk stratification and referral timings). Limb- or life-threatening problems (ulcer with fever/sepsis, ulcer with ischaemia, suspected deep infection, gangrene) → refer immediately to acute services and inform the MDT foot service.
- Cardiovascular disease is the leading cause of death in type 2 diabetes.
- Assess cardiovascular and renal status before choosing glucose-lowering medicinesSource: NICE NG28 1.11.1
- Statins, BP and antiplatelets: see Section 7.
- Tell people at their annual review that diabetes raises the risk of periodontitis (gum disease), and that treating it can improve glucose control.
- Encourage regular dental reviewsSource: NICE NG28 1.37
🚩 Red Flags — Do Not Miss
🚩
New foot ulcer, spreading cellulitis, gangrene or suspected osteomyelitis — immediate acute referral if limb/life-threatening; otherwise MDT foot service within 1 working day (NICE NG19)
🚩
Hot, swollen foot with intact skin in a person with neuropathy — suspect acute Charcot foot — offload and refer within 1 working day
🚩
Sudden visual loss or vitreous haemorrhage — emergency ophthalmology
🚩
Sustained eGFR fall ≥25% with category change in a year — review nephrotoxic drugs and refer (NICE NG203)
Lifestyle Essentials
Tabs keep this tea-break sized
- Same healthy eating as everyone: high-fibre, low-glycaemic-index carbohydrate (fruit, vegetables, wholegrains, pulses), low-fat dairy, oily fish, and less saturated and trans fat
- Individualise carbohydrate, alcohol and meal patterns — especially to reduce hypos on insulin or sulfonylureas
- A little sugar-containing food can be swapped for other carbohydrate, but watch total energy
- Discourage foods marketed as “diabetic”
- Advice should come from someone with nutrition expertise and fit the person’s culture and beliefsSource: NICE NG28 1.3
- Low-energy and very-low-energy diets: follow the NHS Type 2 Diabetes Path to Remission Programme and NICE NG246 (overweight and obesity management)Source: NICE NG28 1.3.4
- Bariatric surgery for recent-onset type 2 diabetes: see NICE NG246 surgical recommendationsSource: NICE NG28 1.4.1
- Use the word “remission”, not “cure” — keep annual reviews and eye screening going.
✅ Patient script: “For some people, losing a good amount of weight early on can put type 2 diabetes into remission. There’s an NHS programme that can help — would you like to hear about it?”
- Adults: at least 150 minutes of moderate activity a week (e.g. brisk walking), plus muscle-strengthening on 2 or more days, and break up long periods of sittingSource: UK Chief Medical Officers’ physical activity guidelines 2019
- Start low, go slow if previously inactive; check feet after exercise if neuropathic.
- If on insulin or a sulfonylurea: more activity can cause hypos — carry fast-acting glucose.
| Option | Dose & regimen | Duration | Notes |
|---|---|---|---|
| Varenicline (first choice) | Days 1–3: 0.5 mg once daily; days 4–7: 0.5 mg twice daily; day 8 onwards: 1 mg twice daily. Start 1–2 weeks before quit date | 12 weeks (a further 12 weeks may be considered if quit) | Back on the UK market as a generic; can lower to 0.5 mg twice daily if not tolerated. Ask about mood changes |
| Combination NRT (first choice alternative) | Long-acting patch plus a short-acting product; strength according to dependence — dose depends on product (check BNF/product literature) | Usually 8–12 weeks | Dose not reproduced here because it varies by product; not verified for this page |
| Cytisine; nicotine vapes | Per product regimen / stop smoking service | Per service | Also listed by NCSCT as first-choice options |
Sources: varenicline — UK SmPC; first-choice options — NCSCT (2024–25). Refer to local stop smoking services; see also NICE NG209.
- Low-risk limit: no more than 14 units a week, spread over 3 or more daysSource: UK Chief Medical Officers 2016
- Alcohol can cause delayed hypos (overnight) in people on insulin or sulfonylureas — eat carbohydrate and check glucose before bed.
- Hypos can look like drunkenness — advise carrying diabetes ID.
- Screen with AUDIT-C at the annual review; brief intervention if positive.
- Diabetes distress (the emotional burden of living with diabetes) is common and different from depression — ask about it.
- For diabetes with an eating disorder (including insulin omission for weight control) see the diabetes section of NICE NG69Source: NICE NG28 1.1.5
- Use non-judgemental language — NICE now points to NHS England’s Language MattersSource: NICE NG28 1.9.5
📘 Structured education: Offer structured education at diagnosis, with annual reinforcement; group programmes are preferred, with an equal alternative for those who can’t attend groups (e.g. DESMOND for type 2; DAFNE for type 1).Source: NICE NG28 1.2
⚠️ Keto on a flozin? A very low carbohydrate (20–50 g/day) or ketogenic diet raises the risk of DKA on an SGLT-2 inhibitor. Ask patients to talk to you first; the SGLT-2 inhibitor may need to be paused for the duration.Source: NICE NG28 1.21.3
📘 The big shift: SGLT-2 inhibitors and GLP-1 receptor agonists are recommended “as much for their cardiovascular and renal benefits as for their glycaemic benefits”. So they are no longer just “add-ons when HbA1c is high”.Source: NICE NG28 2026
Starting Treatment: The Step-by-Step Regime
For most adults with type 2 diabetes — MR metformin first, then an SGLT-2 inhibitor (NICE NG28 1.13 & 1.20)
📘 Does everyone go up to the maximum dose? Nearly — but the NICE wording is the maximum tolerated dose: the highest dose that works without side effects. For many people that is 2 g of MR metformin; for some it is 1 g or 1.5 g because of stomach upset. Once they are at their maximum tolerated dose, that is the moment to add the SGLT-2 inhibitor. You don’t wait for the HbA1c to fail — the flozin is there for heart and kidney protection as much as for glucose.Source: NICE NG28 1.13.1, 1.20.2 and “Terms used”
| When | What to do | Dose |
|---|---|---|
| Before starting | Baseline HbA1c, eGFR, urine ACR, BP, BMI; CHAFE-O assessment; check DKA risk factors and frailty; explain sick day rules | — |
| Day 1 | Start MR metformin with the evening meal | 500 mg once daily |
| After 10–15 days | If tolerated, increase | 1 g once daily (evening meal) |
| After a further 10–15 days | If tolerated, increase | 1.5 g once daily |
| After a further 10–15 days | If tolerated, increase to maximum | 2 g once daily (maximum) |
| Side effects at any step | Drop back to the last dose that was comfortable — this is their maximum tolerated dose. Stay there | e.g. 1 g or 1.5 g once daily |
| As soon as metformin is at maximum tolerated dose | Add the SGLT-2 inhibitor (no titration needed) | Dapagliflozin 10 mg once daily (first choice while cheapest). Alternative: empagliflozin 10 mg once daily |
| 3–6 months later | HbA1c, eGFR, weight, side effects, adherence. If HbA1c ≥58 mmol/mol, intensify per the pathway tabs below | — |
So reaching 2 g takes about 30–45 days at minimum. Sources: Glucophage SR UK SmPC (500 mg steps every 10–15 days, max 2 g once daily with evening meal); NICE NG28 1.20.2 (start SGLT-2 as soon as metformin is at maximum tolerated dose); NHS South West London ICB SGLT-2i guidance (doses); NICE NG28 2026 rationale (supports dapagliflozin while the least expensive SGLT-2 inhibitor).
💊 Prescribing Pearl — which flozin? NICE recommends SGLT-2 inhibitors as a class, and says to use the least expensive suitable one. It supports dapagliflozin while generic dapagliflozin is the cheapest. Dapagliflozin 10 mg once daily — one dose, no titration, long term. If eGFR is 20–30: dapagliflozin or empagliflozin (with a DPP-4 inhibitor instead of metformin). CKD initiation limits: dapagliflozin eGFR ≥25; empagliflozin eGFR ≥20.
⚠️ Exceptions to the standard route: Metformin not tolerated even at 500 mg, or contraindicated: SGLT-2 inhibitor alone. Frail: only add the SGLT-2 if frailty doesn’t put them at risk of dehydration/low BP. Already stable on standard-release metformin: they can stay on it. ASCVD: once tolerating the SGLT-2, add semaglutide 0.25 mg weekly ×4 weeks → 0.5 mg → up to 1 mg. eGFR <30: no metformin — see the CKD tab.
✅ What to say: “We’ll start with one slow-release metformin tablet with your evening meal and add one more tablet every couple of weeks, as long as your stomach is happy. Once you’re on the dose that suits you, we’ll add a second tablet, dapagliflozin, once a day. That one protects your heart and kidneys as well as lowering your sugar.”
🛑 Before you add the SGLT-2 inhibitor: Don’t start if they are unwell, dehydrated, on a very low carbohydrate/ketogenic diet, or you suspect type 1/LADA. Warn about genital thrush and to stop it and check ketones if vomiting or unwell. Some NHS renal guidance notes a small early eGFR dip and suggests rechecking renal function around a month after starting.Source: NICE NG28 1.21; NHS Somerset CKD guidance
🧠 Mnemonic: CHAFE-O — which pathway? (then pick a tab below)
C
CKD — check eGFR — it changes the options
H
Heart failure — any ejection fraction
A
Atherosclerotic CVD — MI, angina, TIA/stroke, PAD → add semaglutide
F
Frailty — SGLT-2 only if safe; fewest medicines
E
Early onset — diagnosed before 40 → consider GLP-1 RA/tirzepatide
O
Obesity — after 3 months → consider GLP-1 RA/tirzepatide
Choose the Pathway
Initial and further medicines by comorbidity (NICE NG28 1.13–1.31)
✅ Initial medicines:
- Offer MR metformin + an SGLT-2 inhibitor
- If metformin contraindicated/not tolerated: SGLT-2 inhibitor alone
- GLP-1 RAs/tirzepatide are not recommended as initial therapy here
📘 If more is needed to reach target:
- Add a DPP-4 inhibitor
- If contraindicated, not tolerated or not effective: add a sulfonylurea, pioglitazone or an insulin-based treatment
✅ Initial medicines:
- Offer MR metformin + an SGLT-2 inhibitor (any ejection fraction)
- If metformin unsuitable: SGLT-2 inhibitor alone
📘 If more is needed to reach target:
- Add a DPP-4 inhibitor
- Then a sulfonylurea or insulin
- Pioglitazone is contraindicated in heart failure
✅ Initial medicines:
- Offer MR metformin + SGLT-2 inhibitor + subcutaneous semaglutide (Ozempic) up to 1 mg weekly
- If metformin unsuitable: SGLT-2 inhibitor + semaglutide
- If ASCVD develops after starting treatment: add semaglutide
📘 If more is needed to reach target:
- Add a sulfonylurea, pioglitazone or an insulin-based treatment
- ASCVD = coronary disease (MI, unstable angina), cerebrovascular disease (TIA, ischaemic stroke) or peripheral arterial disease
✅ Initial medicines:
- eGFR >30: MR metformin + SGLT-2 inhibitor (SGLT-2 alone if metformin unsuitable)
- eGFR 20–30: dapagliflozin or empagliflozin + a DPP-4 inhibitor
- eGFR <20: consider a DPP-4 inhibitor; if unsuitable, pioglitazone or insulin
📘 If more is needed to reach target:
- Consider adding a DPP-4 inhibitor
- Then pioglitazone, a sulfonylurea (only if eGFR >30) or insulin
- SGLT-2 glucose-lowering fades below eGFR 45, but heart/kidney protection continues
✅ Initial medicines:
- Offer MR metformin
- Only add an SGLT-2 inhibitor if frailty does not put them at risk (e.g. volume depletion, low BP)
- If metformin unsuitable: SGLT-2 (if safe) or DPP-4 inhibitor alone
- Aim for the smallest number of medicines at the lowest effective dose
📘 If more is needed to reach target:
- Consider a DPP-4 inhibitor
- Then pioglitazone, a sulfonylurea or insulin
- Remember: sulfonylureas and insulin raise the risk of hypos and falls
✅ Initial medicines:
- Offer MR metformin + SGLT-2 inhibitor
- Consider adding a GLP-1 RA (cardiovascular, renal and glycaemic benefit) or tirzepatide (glycaemic benefit)
- Early onset = diagnosed before age 40
📘 If more is needed to reach target:
- Consider a GLP-1 RA or tirzepatide if not already taking
- If these are unsuitable: DPP-4 inhibitor, then sulfonylurea, pioglitazone or insulin
- If already on a GLP-1 RA/tirzepatide: add sulfonylurea, pioglitazone or insulin
- Discuss contraception — weight loss can improve fertility
✅ Initial medicines:
- Offer MR metformin + SGLT-2 inhibitor
- If weight loss is the main aim, use NICE NG246 (obesity) instead
📘 If more is needed to reach target:
- After at least 3 months of initial therapy: consider a GLP-1 RA or tirzepatide
- If unsuitable/ineffective: DPP-4 inhibitor, then sulfonylurea, pioglitazone or insulin
- If already on GLP-1 RA/tirzepatide: add sulfonylurea, pioglitazone or insulin
⚠️ More than one comorbidity? Make a shared decision about which to prioritise, taking into account medicines needed for heart/kidney protection, contraindications (e.g. metformin with eGFR <30) and frailty.Source: NICE NG28 1.9.3
🔀 Starting medicines safely (one at a time)
START: Newly diagnosed type 2 — CHAFE-O assessment done, sick day rules explained
↓
Start MR metformin 500 mg with evening meal; increase by 500 mg every 10–15 days to 2 g (or maximum tolerated dose)
↓
❓ Metformin at maximum tolerated dose and SGLT-2 appropriate?
YES ↓NO ↓
Add dapagliflozin 10 mg once daily (or empagliflozin 10 mg once daily)
Metformin not tolerated? SGLT-2 inhibitor alone (or DPP-4 if frail and SGLT-2 unsafe)
↓
❓ ASCVD or early onset?
YES ↓NO ↓
Once SGLT-2 at maximum tolerated dose: add semaglutide (ASCVD) or consider GLP-1 RA/tirzepatide (early onset)
Review HbA1c in 3–6 months; intensify if ≥58 mmol/mol
Drug-by-Drug Prescribing Guide
Adult doses verified against BNF/SmPC/NICE-linked NHS sources
| Formulation | Dose | Duration |
|---|---|---|
| MR metformin (first line) | 500 mg once daily with the evening meal. Increase in 500 mg steps every 10–15 days (1 g → 1.5 g → 2 g) to a maximum of 2 g once daily with the evening meal, as tolerated. If control not reached on 2 g once daily, 1 g twice daily with food may be considered | Long term |
| Standard-release metformin (if already stable on it, or swallowing difficulties) | 500 mg with breakfast for at least 1 week, then 500 mg twice daily for at least 1 week, then 500 mg three times daily; maximum 2 g daily in divided doses with meals. Can be crushed/available as liquid | Long term |
Sources: Glucophage SR UK SmPC (MR titration); BNF as summarised in UWE prescribing review (standard-release); NICE NG28 1.23.1 (people tolerating standard-release can continue).
- eGFR <30: contraindicated — stopSource: NICE NG28 1.9.3
- eGFR 30–44: review; consider a maximum of 1 g dailySource: NICE via GPnotebook
- eGFR 45–59: check SmPC maximum and monitor renal function more often
- Stop during dehydrating illness (sick day rules) and restart when well
- Long-term use can lower vitamin B12 — check if symptoms (e.g. neuropathy, anaemia)
✅ You might say: “This is a slow-release version, which is much kinder on the stomach. Take it with your evening meal. If you get vomiting or diarrhoea, pause it until you’re eating and drinking again.”
| Drug | Dose | Renal notes | Duration |
|---|---|---|---|
| Dapagliflozin (first choice while cheapest) | 10 mg once daily | CKD indication: avoid starting if eGFR <25 | Long term |
| Empagliflozin (alternative) | 10 mg once daily (SmPC allows 25 mg once daily for extra glycaemic control) | CKD indication: avoid starting if eGFR <20 | Long term |
Sources: NICE NG28 2026 (dapagliflozin supported while least expensive; dapagliflozin or empagliflozin for eGFR 20–30); NHS South West London ICB SGLT-2i guidance (doses, eGFR initiation limits).
- Per 1,000 people over 3 years, NICE’s evidence showed MACE fell from 123 to 107–115, and heart-failure admissions from 54 to 26–40
- Genital infections: about 10–100 per 1,000
- DKA, Fournier’s gangrene or other severe infections: 1 per 1,000 or fewerSource: NICE NG28 2026 rationale
- Check DKA risk: previous DKA, current illness, dehydration risk, very low carbohydrate/ketogenic diet — fix what you can firstSource: NICE NG28 1.21.1–1.21.2
- Check frailty, BP and diuretic use (volume depletion)
- Suspect insulin deficiency (type 1/LADA)? Do not start — seek advice
✅ You might say: “This tablet makes you pass extra sugar in the urine. It protects your heart and kidneys too. Keep the genital area clean and dry. If you’re being sick, can’t eat or drink, or feel breathless and unwell, stop it and get checked — including a ketone test.”
| Drug | Dose | Renal adjustment |
|---|---|---|
| Sitagliptin (first choice: generic, best value) | 100 mg once daily | eGFR 30 to <45: 50 mg once daily; eGFR <30: 25 mg once daily |
| Linagliptin (alternative) | 5 mg once daily | No dose adjustment needed in renal impairment |
Sources: NHS North West ICB sitagliptin switching guidance (2025); linagliptin UK SmPC. Long-term treatment; review effect at 3–6 months.
🛑 Never combine: Do not prescribe a DPP-4 inhibitor together with a GLP-1 RA or tirzepatide.Source: NICE NG28 1.24.6
| Drug | Dose | Notes |
|---|---|---|
| Semaglutide s/c (Ozempic) — first choice in ASCVD | 0.25 mg once weekly for 4 weeks (starter dose only), then 0.5 mg once weekly; after at least 4 weeks may increase to 1 mg once weekly | NICE recommends only up to 1 mg weekly. Reduce sulfonylurea/insulin dose to lower hypo risk |
| Dulaglutide, liraglutide; tirzepatide | Follow the BNF/SmPC titration schedule | Doses not reproduced here: not verified for this build |
Sources: Ozempic UK SmPC; NICE NG28 2026 (class includes liraglutide, dulaglutide, semaglutide; tirzepatide for glycaemic benefit).
- Stop if BMI falls below 18.5 kg/m²Source: NICE NG28 1.24.3
- Stop if not helping reach glycaemic targets and not being taken for cardiovascular benefitSource: NICE NG28 1.24.4
- MHRA: strengthened warnings on acute pancreatitis (including necrotising/fatal); warn about severe abdominal pain
- MHRA: semaglutide and non-arteritic anterior ischaemic optic neuropathy (NAION) — sudden visual loss needs urgent review
- MHRA: potential for misuse
- Common: nausea, vomiting, diarrhoea — usually settle with slow titration
- Women, trans men and non-binary people of childbearing potential: explain that weight loss may improve fertility, effective contraception is needed while taking it, and contraception should continue for a period after stopping (see MHRA GLP-1 guidance for the medicine-specific time)Source: NICE NG28 1.9.4
| Drug | Dose | Notes |
|---|---|---|
| Gliclazide (standard-release) — first choice | Initially 40–80 mg daily with breakfast; adjust to response; up to 160 mg as a single dose; higher doses twice daily; maximum 320 mg daily | Useful for symptomatic hyperglycaemia; review when glucose back on target |
| Gliclazide MR (alternative) | Initially 30 mg once daily with breakfast; maximum 120 mg once daily | Once-daily option |
Sources: NHS Highland formulary (BNF dosing); NICE NG28 1.8.1 (consider insulin or a sulfonylurea for symptomatic hyperglycaemia). Glimepiride dosing not verified for this build — check BNF.
⚠️ Cautions: Hypoglycaemia (worse in older people, renal impairment, missed meals), weight gain, falls in frailty. In CKD, NICE only lists a sulfonylurea as an option if eGFR >30. Aim for HbA1c 53 (not 48). DVLA rules apply (Section 11).
| Drug | Dose | Notes |
|---|---|---|
| Pioglitazone | 15 mg or 30 mg once daily; may increase to a maximum of 45 mg once daily | Review at 3–6 months and stop if inadequate response; confirm ongoing benefit at routine reviews |
Source: pioglitazone UK SmPC.
🛑 Contraindicated: Heart failure or history of heart failure (NYHA I–IV); current or previous bladder cancer; uninvestigated visible haematuria; hepatic impairment. Watch for fluid retention, weight gain and fractures, especially in older people.Source: Pioglitazone SmPC; NICE NG28 1.9.2
- Offer structured education: injection technique and site rotation, self-monitoring, titration, diet, DVLA, hypo managementSource: NICE NG28 1.32.1
- When starting insulin: continue metformin; stop other medicines used only for glucose; discuss continuing those taken for cardiovascular or weight benefit (e.g. SGLT-2, semaglutide)Source: NICE NG28 1.32.2
- Start with basal insulin once or twice daily; consider adding short/rapid-acting (or a pre-mixed insulin) especially if HbA1c ≥75 mmol/molSource: NICE NG28 1.33
- Choose the least expensive suitable option, including biosimilars; follow MHRA advice to avoid errors with biosimilar, high-strength and combination insulinsSource: NICE NG28 1.34–1.35
- Starting doses and titration: follow your local protocol or TREND “Basal insulin initiation” — not reproduced here
🛑 Levemir (insulin detemir) is being discontinued: Do not start anyone new on it. NHS England (22 June 2026) asks that all switches are completed by 30 November 2026. There is no direct equivalent; guidance suggests considering a 10–20% dose reduction when switching, with closer monitoring — follow ABCD/PCDO switching guidance.
💊 Prescribing Pearl — the eGFR ladder: >30: metformin + SGLT-2. 20–30: dapagliflozin/empagliflozin + DPP-4 (stop metformin). <20: DPP-4, then pioglitazone or insulin. Linagliptin needs no renal dose change; sitagliptin does.
🛑 Euglycaemic DKA: On an SGLT-2 inhibitor, DKA can occur with glucose that is only mildly raised. Unwell + vomiting/abdominal pain/breathless = check blood ketones. Stop the SGLT-2 inhibitor if DKA is suspected. Follow MHRA advice to monitor ketones when treatment is interrupted for surgery or acute serious illness.
✅ Reviewing medicines: Optimise before switching (side effects, doses, adherence, diet). Keep SGLT-2 inhibitors for heart/kidney benefit even if glucose targets aren’t met. If someone has reached their glycaemic and weight targets, consider continuing what got them there. If the response to treatment doesn’t fit type 2, revisit the diagnosis.Source: NICE NG28 1.22–1.24
⚠️ Health inequalities: NICE’s analysis of almost 590,000 records found SGLT-2 inhibitors under-prescribed to women, older people and Black people. Run a practice search for eligible people not on an SGLT-2 inhibitor and invite them in.Source: NICE NG28 1.12; NICE news 18 Feb 2026
🃏 Flip-card prescribing practice
Cardiovascular Risk Reduction
The glucose number is only one of the numbers that matter
| Situation | Clinic BP target | Home/ambulatory target |
|---|---|---|
| Type 2 diabetes, age under 80 | Below 140/90 | Below 135/85 |
| Age 80 and over | Below 150/90 | Below 145/85 |
| Diabetes with CKD and abnormal ACR | Below 130/80 | — |
Sources: NICE NG136 (hypertension; NG28 no longer has its own BP section); NICE NG203 (CKD). Use clinical judgement in frailty; use standing BP if postural hypotension.
🔀 Hypertension drug steps in type 2 diabetes (any age or family origin)
START: Step 1: ACE inhibitor or ARB (consider an ARB first if Black African or African-Caribbean family origin)
↓
Step 2: add a calcium-channel blocker or a thiazide-like diuretic
↓
Step 3: ACE-i/ARB + CCB + thiazide-like diuretic
↓
Step 4: confirm resistant BP (ABPM/HBPM, adherence). Potassium ≤4.5 → consider low-dose spironolactone; >4.5 → alpha- or beta-blocker; or seek expert advice
💊 Prescribing Pearl: Ramipril (first line): start 2.5 mg once daily for hypertension; double every 2–4 weeks to a maximum of 10 mg daily. Losartan (second line/ACE-i cough): 50 mg once daily, may increase to 100 mg. Check U&E 1–2 weeks after starting or increasing. Never combine ACE-i with ARB. CCB and thiazide-like diuretic doses: check BNF.Source: UK SmPCs; NICE NG136
- Type 2: offer atorvastatin 20 mg for primary prevention if QRISK3 is 10% or more — and don’t rule it out below 10% if the person wants it or risk may be underestimated
- Type 1: offer a statin (atorvastatin 20 mg) if over 40, diabetes for more than 10 years, established nephropathy, or other CVD risk factors (QRISK3 is not used)
- CKD: don’t use a risk tool if eGFR <60 and/or albuminuria — risk is already high
- Established CVD: atorvastatin 80 mg (lower if interactions, side-effect risk or preference)
- Targets: primary prevention — more than 40% fall in non-HDL cholesterol at 3 months; secondary prevention — LDL-C 2.0 mmol/L or less, or non-HDL-C 2.6 mmol/L or lessSource: NICE NG238 (via NICE indicators, DiabetesontheNet, GPnotebook)
🛑 Antiplatelets: Do not offer aspirin or clopidogrel to adults with type 2 diabetes who do not have cardiovascular disease. For those with CVD, follow NICE’s CVD and acute coronary syndrome guidance.Source: NICE NG28 1.45
✅ Patient script: “In diabetes, the heart and kidneys are what we most want to protect. That’s why I’m talking about your blood pressure and cholesterol as much as your sugar.”
🧠 Mnemonic: HAK — the DKA triad
H
Hyperglycaemia — glucose >11 mmol/L or known diabetes (glucose may be near-normal on a flozin)
A
Acidosis — bicarbonate <15 and/or venous pH <7.3
K
Ketones — blood ketones ≥3.0 mmol/L or urine 2+ or more
DKA vs HHS
Side by side
| Feature | DKA | HHS |
|---|---|---|
| Diagnosis | Ketones ≥3.0 mmol/L (or urine 2+ or more) and glucose >11 mmol/L or known diabetes and bicarbonate <15 mmol/L and/or venous pH <7.3 | Very high glucose (typically ≥30 mmol/L), high osmolality (typically ≥320 mOsm/kg), marked dehydration, without significant ketosis or acidosis |
| Typical patient | Type 1 (any age), or anyone on an SGLT-2 inhibitor | Older person with type 2, often new or with infection |
| Onset | Hours to 1–2 days | Days to weeks |
| Clues | Vomiting, abdominal pain, deep sighing (Kussmaul) breathing, pear-drop breath, drowsiness | Profound dehydration, confusion, focal neurology, seizures; high VTE risk |
| Glucose on a flozin | May be only mildly raised (euglycaemic DKA) | — |
| GP action | 999/same-day hospital | 999/same-day hospital |
DKA criteria: JBDS “Management of DKA in adults” (revised March 2023). HHS: JBDS guidance; HHS carries a higher mortality than DKA. Hospital management (IV fluids, insulin, potassium) follows JBDS protocols.
Hypoglycaemia
Treat first, investigate why second
🔀 Hypoglycaemia (glucose below 4.0 mmol/L)
START: Hypo suspected or glucose <4.0 mmol/L
↓
❓ Conscious, orientated and able to swallow?
YES ↓NO ↓
Give 15–20 g quick-acting carbohydrate: e.g. 4–5 GlucoTabs, 60 mL glucose juice, or 150–200 mL pure fruit juice. Recheck in 10–15 min; repeat up to 3 times
Can swallow but confused/uncooperative: 1.5–2 tubes of 40% glucose gel into the cheek. Unconscious/fitting: nothing by mouth, recovery position, glucagon 1 mg IM (once only), call 999
↓
Once ≥4.0 mmol/L: give a longer-acting carbohydrate (e.g. 2 biscuits, a slice of bread, 200–300 mL milk, or the next meal); 40 g if glucagon was used
⚠️ Watch-outs: Glucagon may be less effective after sulfonylurea-induced hypos, in malnutrition and liver disease. Sulfonylurea hypos can recur for many hours — low threshold for admission. Think about DVLA after any severe hypo.
📞 When to Call 999 / Admit
🚩
Suspected DKA or HHS — 999 / same-day hospital
🚩
Hypo not responding after repeated treatment, or unconscious/fitting — 999
🚩
Unwell on an SGLT-2 inhibitor with vomiting or abdominal pain — check blood ketones; if raised → same-day hospital
🚩
Severe hypo on a sulfonylurea — consider admission — prolonged hypos
🚩
Chest pain, stroke symptoms — 999 (FAST)
📘 What NICE now expects: Every person’s treatment plan should include clear sick day rules: whether medicines change if unwell or having surgery; which to stop if there’s a risk of dehydration, vomiting or diarrhoea (e.g. metformin, SGLT-2 inhibitors); how to adjust insulin; and how to restart after recovery.Source: NICE NG28 1.10.1
🧠 Mnemonic: SADMANS — medicines to pause during dehydrating illness (widely used UK sick day aid)
S
Sulfonylureas — risk of hypos if not eating — seek advice about dose
A
ACE inhibitors — “-pril” — kidney risk when dehydrated
D
Diuretics — “-ide”, e.g. furosemide, indapamide
M
Metformin — lactic acidosis risk with dehydration/AKI
A
ARBs — “-sartan”
N
NSAIDs — e.g. ibuprofen, naproxen
S
SGLT-2 inhibitors — “-flozin” — DKA and volume depletion
🛑 Pause when: Vomiting or diarrhoea (more than minor), fever with sweats/shaking, or unable to eat and drink normally.
✅ Restart when: Eating and drinking normally again, usually after 24–48 hours. If unsure, speak to the practice, pharmacist or NHS 111.
⚠️ Insulin users: Never stop insulin. Check glucose at least 4 times a day. Type 1 with glucose ≥15 mmol/L, or anyone on an SGLT-2 inhibitor who is unwell: check ketones and seek help if raised.
💊 Prescribing Pearl: Give written sick day guidance (e.g. TREND “Managing diabetes during intercurrent illness”), document it, and reinforce it at every medicine review. Ask: “If you were being sick tomorrow, which of your tablets would you stop — and when would you start them again?”
📊 How are we doing? In England in 2024/25, 58.2% of people with type 2 (and other) diabetes received all 8 audited care processes, and only 45.2% met all 3 treatment targets (HbA1c, BP and statin prescription).Source: OHID Diabetes profile, April 2026 (National Diabetes Audit data)
The 9 Care Processes
Every person with diabetes, every year
| # | Care process | Why it matters |
|---|---|---|
| 1 | HbA1c | Glycaemic control against individual target |
| 2 | Blood pressure | Largest modifiable CV and renal risk |
| 3 | Cholesterol | Statin decisions and targets |
| 4 | Serum creatinine (eGFR) | Drug doses and CKD staging |
| 5 | Urine albumin:creatinine ratio | Early kidney damage; ACE-i/ARB and SGLT-2 decisions |
| 6 | Foot surveillance | Risk-stratify (NICE NG19) |
| 7 | BMI | Weight management and GLP-1/tirzepatide decisions |
| 8 | Smoking status | Offer support every time |
| 9 | Diabetic eye screening | Via the NHS Diabetic Eye Screening Programme |
The 8 processes excluding eye screening are measured by the National Diabetes Audit; eye screening is recorded separately.
Beyond the Checklist
Tap to expand
- Medicines review including sick day rules, hypos, adherence, SGLT-2 eligibility (inequalities)
- Structured education offered/refreshed
- Periodontitis advice and dental review
- Erectile dysfunction — offer to discuss
- Mood and diabetes distress
- Frailty assessment where relevant
- Driving and DVLA advice documented
- Contraception/pre-conception advice for people who could become pregnant
| Vaccine | Who | Notes |
|---|---|---|
| Influenza | All adults with diabetes | Annual autumn programme |
| Pneumococcal — PCV20 | Clinical risk groups aged 2 and over (includes diabetes) and everyone aged 65 and over | PCV20 has replaced PPV23 in the UK programme (UKHSA PGD valid from 17 December 2025) |
| COVID-19 | Per the current national programme | Eligibility changes each season — check UKHSA/NHS England |
| Shingles (Shingrix, 2 doses) | Turning 65; everyone 70–79; severely immunosuppressed aged 18 and over | Eligible until 80th birthday (2nd dose by 81st) |
Sources: UKHSA (PCV20 PGD, Dec 2025); NHS.uk shingles eligibility; UKHSA shingles programme 2025–26. Diabetes alone is not a shingles eligibility criterion.
✅ Patient script to open the review: “Before we look at the numbers — what’s been the hardest part of living with diabetes this year?”
DVLA Essentials
Always document driving advice
- Must notify the DVLA (Group 1, car/motorbike)
- Adequate hypo awareness; no more than 1 episode of severe hypoglycaemia (needing another person’s help) while awake in the last 12 months, and the most recent more than 3 months ago
- Appropriate glucose monitoring at times relevant to driving: check no more than 2 hours before driving and at least every 2 hours while driving
- Hypos during established sleep are no longer counted for Group 1 unless there are concerns about awareness
- Licence usually for 1, 2 or 3 years
- Sulfonylureas (and glinides): may drive and need not notify the DVLA if no more than 1 severe hypo while awake in 12 months (latest >3 months ago), appropriate glucose monitoring, under regular review and no other notifiable condition
- Diet or non-hypo tablets: generally no need to notify unless complications (e.g. visual problems)
- Two or more severe hypos while awake in 12 months: must not drive and must notify DVLA
- Group 2 (bus/lorry) rules are stricter: on insulin, full hypo awareness and no severe hypos in the last 12 months
- Group 2 drivers on a sulfonylurea must notify the DVLA
- Refer to the DVLA “Assessing fitness to drive” guide
🛑 Hypo while driving: Stop safely, remove keys from the ignition, move to the passenger seat, treat the hypo, and do not drive until 45 minutes after glucose is back to normal.Source: DVLA advice as summarised by UK driver-medical providers
Travel Checklist
Before the patient books the flight
- Carry a GP letter or diabetes ID listing diagnoses and medicines
- All medicines and monitoring kit in hand luggage; take about twice the usual supplies
- Get travel insurance early and declare all conditions
- Crossing time zones on insulin: ask the diabetes team for a plan; check glucose more often
- Heat can speed insulin absorption (hypos) and spoil insulin — use a cool bag
- GHIC/EHIC for Europe; check vaccinations and malaria advice
⚠️ The GP’s biggest opportunity: Most of the benefit happens before conception. Ask every person with diabetes who could become pregnant about their plans and contraception at every review.
Pre-existing Diabetes
Pre-conception and medicines
- Refer to a pre-conception diabetes clinic
- Folic acid 5 mg daily from planning until 12 weeks of pregnancy
- Aim for HbA1c below 48 mmol/mol if achievable without problematic hypos; any fall towards target helps
- Strongly advise against pregnancy if HbA1c is above 86 mmol/mol until it is lower
- Up to monthly HbA1c while planning; offer a glucose meter
- Weight-loss advice if BMI above 27
- Retinal and renal assessment before pregnancy
- Type 1: offer blood ketone strips and meterSource: NICE NG3 (last updated Dec 2020)
🛑 Stop before pregnancy: ACE inhibitors, ARBs and statins; all oral glucose-lowering medicines except metformin (switch to insulin).
✅ Can use: Metformin (alongside or instead of insulin); insulin. GLP-1 RAs/tirzepatide: stop and use contraception per MHRA advice before trying to conceive.
Gestational Diabetes
Diagnosis and follow-up
- Diagnosis: 75 g OGTT — fasting ≥5.6 mmol/L or 2-hour ≥7.8 mmol/L
- After birth: do not routinely offer an OGTT. Offer a fasting plasma glucose at 6–13 weeks (or HbA1c if after 13 weeks)
- Then HbA1c every year; code “history of gestational diabetes”
- Lifestyle advice: weight, diet, activity; explain future GDM and type 2 riskSource: NICE NG3
📘 Correction to older teaching: A postnatal OGTT at 6 weeks is no longer recommended after gestational diabetes — use fasting glucose at 6–13 weeks, then annual HbA1c.
📘 Plan 6–8 weeks ahead: Ramadan lasts 29–30 days and moves about 10–11 days earlier each year. People eat before dawn (suhoor) and after sunset (iftar). Blood tests, glucose checks and injections given for non-nutritional purposes are generally considered not to break the fast — suggest the patient checks with their imam if unsure.
Risk Stratification
IDF–DAR 2021 scoring
| IDF-DAR total score | Risk | Advice |
|---|---|---|
| 0 to 3 | Low | Can usually fast with education and medicine adjustment |
| 3.5 to 6 | Moderate | Advise not to fast; if they choose to, education, monitoring and adjustment |
| More than 6 | High | Should not fast |
Source: IDF–DAR Practical Guidelines 2021. Scores add up elements such as diabetes type/duration, hypos (unawareness 6.5; recent severe 5.5), DKA/HHS, HbA1c, treatment, complications, pregnancy, frailty, physical labour and fasting hours.
🛑 Break the fast if: Glucose below 3.9 mmol/L or above 16.6 mmol/L, hypo symptoms, or acute illness.Source: IDF–DAR 2021 (as summarised in Diabetes & Primary Care)
Adjusting Medicines
Common primary care regimens
| Medicine | During Ramadan |
|---|---|
| Metformin (once daily) | Take with the sunset meal (iftar) |
| Metformin (twice daily) | Take with iftar and the pre-dawn meal (suhoor) |
| Sulfonylurea | Once daily: take at iftar; twice daily: reduce the suhoor dose if well controlled |
| SGLT-2 inhibitor | Take at iftar; encourage fluids during non-fasting hours; watch for dehydration and DKA |
| DPP-4 inhibitor; GLP-1 RA; pioglitazone | Usually no dose change |
| Insulin | Individual plan from the diabetes team before Ramadan |
Summarised from IDF–DAR 2021; see also the BIMA Ramadan Compendium.
✅ Patient script: “I respect that fasting is important to you. Let’s make a plan together so you can fast as safely as possible — and agree when it’s right to break the fast for your health.”
You’ve Got This! 💪
Remember: you don’t need to be a diabetologist to provide excellent diabetes care. You just need to know when to worry, when to treat, and when to refer.
You can confidently diagnose, start MR metformin and a flozin one step at a time, pick the right pathway with CHAFE-O, and run a brilliant annual review. Refer the suspected type 1 in an adult, the pregnancy, the active foot and the falling eGFR. And the one thing never to miss: the unwell patient on a flozin with “normal” sugar — check the ketones.
☕ Now go reward yourself with that well-deserved coffeeClinical accuracy: content checked on 19 September 2026 against NICE NG28 (18 Feb 2026), NG17, NG3, NG19, NG136, NG173, NG203, NG238, PH38, TA943, NICE CKS, JBDS, DVLA, UKHSA, NHS England and UK SmPCs. Where a dose could not be verified for this build, the page says so. Guidelines change — always check the BNF and current NICE guidance before prescribing. © Bradford VTS — bradfordvts.co.uk