🩺 Diabetes for UK GPs
Glucose-ready revision — no sugar-coating required (unless it’s a hypoglycaemic emergency)
Date Updated: March 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
- Understanding the different types of diabetes
- Diagnosis criteria and investigations
- Monitoring targets and HbA1c goals
- Microvascular and macrovascular complications
- Lifestyle management — diet, exercise, weight
- Pharmacological treatment — NICE NG28 (Feb 2026)
- Acute emergencies: DKA, HHS, hypoglycaemia
- Annual reviews and 9 care processes
Quick Facts at a Glance
4.6 million
People with a diabetes diagnosis in the UK (2026 — highest on record)
7.0%
GP-recorded type 2 diabetes prevalence in adults aged 17+ in England (2024)
1 in 5
UK adults have diabetes or pre-diabetes
40%
Increase in type 2 diabetes diagnoses over the past 5 years
17,000
Deaths prevented over 3 years by NICE 2026 SGLT-2 inhibitor recommendations
£560 million
NHS savings from generic dapagliflozin availability (2025/26–2026/27)
Downloads
Downloadable files for this topic are listed below.
path: DIABETES
- antidiabetic drugs - pros cons initiation safety 2020.docx
- diabetes - an overview.ppt
- diabetes and gastroparesis.pdf
- diabetes and renal disease.ppt
- diabetes and the evidence.doc
- diabetes during ramadan 2021.pdf
- diabetes in primary care.ppt
- diabetes in ten steps.pdf
- diabetes protocol aschroft plus sglt2 risk tablet - 2021.docx
- diabetes tutorial framework.doc
- diabetes type II - westcliffe - 2019.pdf
- diabetes- what to do when sick - sick day rules - SADMAN rules.pdf
- hba1c dcct and ifcc.doc
- home glucose monitoring guidelines.doc
- impaired glucose tolerance.doc
- language matters - switch small things you say - for example in diabetes.pdf
- learning plan for diabetes.doc
- medication treatment algorithm for type 2 diabetes by TREND 2020.pdf
- ramadan - a guide for type 2 diabetics.pdf
- steroid therapy induced hyperglycaemia - management.pdf
- type 1 and type 2 diabetes insulin formulary 2021.pdf
- type 2 diabetes management formulary - excluding insulin.pdf
Web Resources
Brainy Bites: GP Wisdom
The things the textbook mentions but your trainer never forgets to tell you
🏆 The NICE 2026 Game-Changer
SGLT-2 inhibitors are now first-line alongside metformin for most newly diagnosed type 2 diabetes patients. Generic dapagliflozin availability is saving the NHS £560 million and preventing 17,000 deaths over 3 years. Know your flozins!
⚖️ Health Inequalities Alert
SGLT-2 inhibitors are under-prescribed to women, older people, and Black patients despite clear cardiovascular and renal benefits. Be proactive in offering these medicines to ALL eligible patients — not just younger white men.
💊 Modified-Release Metformin Matters
NICE 2026 recommends modified-release metformin over standard-release to reduce GI side effects and improve adherence. If a patient stopped metformin due to diarrhoea, consider restarting with the MR formulation.
⚠️ Euglycaemic DKA with SGLT-2 Inhibitors
SGLT-2 inhibitors can cause DKA even with normal blood glucose (euglycaemic DKA). If a patient on a flozin is unwell (vomiting, abdominal pain), check ketones — not just glucose. Stop the SGLT-2 inhibitor during acute illness.
🦶 Foot Ulcer = Urgent Referral
Any new diabetic foot ulcer requires urgent multidisciplinary foot team referral within 24 hours if infected or ischaemic. Don’t wait for it to get worse — early intervention prevents amputations.
📊 Annual Review Completion Rates
Only 50–60% of people with diabetes receive all 9 care processes annually. Use recall systems, opportunistic checks, and QOF targets to improve rates. Every missed check is a missed opportunity to prevent complications.
🎯 HbA1c Targets Are Individualised
Don’t chase a one-size-fits-all HbA1c. Frail elderly patients with limited life expectancy should have relaxed targets (58–64 mmol/mol) to avoid hypoglycaemia. Quality of life matters more than numbers.
🧬 T1DM Can Present at Any Age
Type 1 diabetes can present in adults. Suspect it with rapid onset, significant weight loss, ketosis, or low C-peptide. Don’t assume all adult-onset diabetes is type 2 — missed T1DM causes DKA.
🚗 Driving and Hypoglycaemia
Patients on insulin or sulfonylureas must inform DVLA. Check glucose before driving and every 2 hours on long journeys. Severe hypoglycaemia while driving = 12-month licence revocation. Always advise and document.
🔁 GLP-1 RAs for Established CVD
Per NICE NG28 (2026), subcutaneous semaglutide is recommended for patients with atherosclerotic CVD alongside type 2 diabetes. Cardiovascular benefits are dose-dependent — specialist-initiated and titrated to effective dose.
🧠 Understanding Diabetes
Diabetes mellitus is a group of metabolic disorders characterised by chronic hyperglycaemia due to defects in insulin secretion, insulin action, or both.
- Polyuria — excessive urination
- Polydipsia — excessive thirst
- Polyphagia — excessive hunger
- Ponderal loss — weight loss despite eating
Description: Autoimmune destruction of pancreatic beta cells leading to absolute insulin deficiency. Accounts for ~8% of all diabetes cases.
Key Features:
- Typically presents in childhood/young adults (can occur at any age)
- Acute onset with polyuria, polydipsia, weight loss
- Ketosis-prone (risk of DKA)
- Requires lifelong insulin therapy
- Associated with other autoimmune conditions (thyroid, coeliac)
Management:
- Multiple daily insulin injections or insulin pump — specialist-led
- Carbohydrate counting and dose adjustment
- Regular blood glucose monitoring
- Annual screening for complications
- Specialist diabetes team involvement
Description: Progressive insulin resistance and relative insulin deficiency. Accounts for ~90% of all diabetes cases. Strongly associated with obesity, physical inactivity, and family history.
Key Features:
- Usually diagnosed in adults >40 years (increasingly seen in younger people)
- Insidious onset, often asymptomatic initially
- Strong genetic component (40% risk if one parent affected)
- Associated with metabolic syndrome (obesity, hypertension, dyslipidaemia)
- Not ketosis-prone (except in severe illness)
Management:
- Lifestyle modification (diet, exercise, weight loss)
- Modified-release metformin + SGLT-2 inhibitor first-line (NICE NG28, Feb 2026)
- May eventually require insulin (specialist-initiated)
- Cardiovascular risk factor management
- Regular monitoring and screening for complications
Description: Glucose intolerance first recognised during pregnancy. Affects 3–5% of pregnancies. Usually resolves after delivery but indicates high risk of future type 2 diabetes.
Key Features:
- Diagnosed during routine antenatal screening (OGTT at 24–28 weeks)
- Risk factors: obesity, previous GDM, family history, ethnicity
- Increases risk of macrosomia, birth trauma, neonatal hypoglycaemia
- 50% will develop type 2 diabetes within 10 years
Management:
- Dietary modification and blood glucose monitoring
- Metformin or insulin if targets not met (specialist/obstetric team)
- Close monitoring during pregnancy
- Postnatal OGTT at 6 weeks
- Annual HbA1c screening thereafter
Description: Less common forms of diabetes with specific underlying causes. Always consider these before defaulting to type 2, especially in younger or non-obese patients.
MODY (Maturity Onset Diabetes of the Young):
- Monogenic diabetes due to single gene mutations affecting beta cell function
- Autosomal dominant inheritance — strong family history across 3 generations
- Typically diagnosed <25 years; not overweight; no insulin resistance
- Negative pancreatic autoantibodies; treatment varies by subtype (diet, sulfonylureas, or insulin)
- Genetic testing to confirm subtype; family screening recommended; specialist input required
LADA (Latent Autoimmune Diabetes in Adults):
- Slow-onset Type 1 diabetes presenting in adults (typically >25 years)
- Initially responds to oral agents but eventually requires insulin
- Positive GAD antibodies; low C-peptide; often slim; suspect if “type 2” deteriorating rapidly
Secondary Diabetes:
- Pancreatic: Chronic pancreatitis, cystic fibrosis, haemochromatosis, pancreatic cancer, post-pancreatectomy (Type 3c diabetes)
- Endocrine: Cushing's syndrome, acromegaly, phaeochromocytoma, hyperthyroidism
- Drug-induced: Corticosteroids, antipsychotics (especially clozapine/olanzapine), thiazide diuretics
- Address underlying condition; may require insulin if significant pancreatic damage; specialist input often required
- Pancreatitis (chronic) / Pancreatic cancer
- Acromegaly
- Neoplasia (pancreatic)
- Cushing's syndrome
- Renal failure / haemochromatosis
- Endocrine (phaeochromocytoma, hyperthyroidism)
- Antiretrovirals, antipsychotics, and other drugs (steroids, thiazides)
- Surgery (post-pancreatectomy)
🔬 Diagnosis and Investigations
Accurate diagnosis requires appropriate testing and interpretation of results. Multiple diagnostic criteria exist.
Clinical History
Key questions to ask
Symptoms:
- Polyuria, polydipsia, polyphagia
- Weight loss (especially if eating normally)
- Fatigue, lethargy
- Blurred vision
- Recurrent infections (thrush, UTIs, skin infections)
- Slow wound healing
- Neuropathic symptoms (tingling, numbness)
Risk Factors:
- Age >40 years
- BMI >25 kg/m² (>23 for South Asian)
- Family history (first-degree relative)
- Ethnicity (South Asian, African-Caribbean, Black African)
- Previous gestational diabetes
- Hypertension or cardiovascular disease
- PCOS
- Medications (steroids, antipsychotics)
Physical Examination
Essential examination findings
General:
- BMI and waist circumference
- Blood pressure
- Signs of dehydration
- Acanthosis nigricans (insulin resistance)
Cardiovascular:
- Peripheral pulses
- Carotid bruits
- Heart sounds
Neurological:
- Peripheral sensation (monofilament, vibration)
- Ankle reflexes
- Proprioception
Feet:
- Skin integrity, ulcers
- Deformities (Charcot, clawing)
- Calluses, corns
- Fungal infections
Investigations
Laboratory tests and monitoring
Diagnostic Tests:
| Test | Normal | Pre-diabetes | Diabetes |
|---|---|---|---|
| HbA1c | <42 mmol/mol | 42–47 mmol/mol | ≥48 mmol/mol |
| Fasting Glucose | <6.0 mmol/L | 6.1–6.9 mmol/L | ≥7.0 mmol/L |
| Random Glucose | <7.8 mmol/L | — | ≥11.1 mmol/L |
| OGTT (2-hour) | <7.8 mmol/L | 7.8–11.0 mmol/L | ≥11.1 mmol/L |
⚠️ HbA1c Limitations
HbA1c may not be accurate in:
- Haemoglobinopathies (sickle cell, thalassaemia)
- Haemolytic anaemia, recent blood loss
- Iron deficiency anaemia, splenectomy
- Pregnancy
- Children and young people
Use fasting glucose or OGTT in these situations.
Diagnosing Diabetes
Symptomatic vs Asymptomatic Criteria
SYMPTOMATIC Patients
Symptoms of hyperglycaemia (polyuria/polydipsia, unexplained weight loss, visual blurring, genital thrush, lethargy) PLUS EITHER:
- HbA1c ≥ 48 mmol/mol (LAB TESTING) — Type 2 diabetes is diagnosed in adults who are not pregnant and do not have haemoglobinopathy or haemolytic anaemia
- Fasting Blood Glucose ≥ 7.0 mmol/L
- Random Plasma Glucose ≥ 11.1 mmol/L
WHO guidance: Diagnosis should be confirmed with a repeat HbA1c test, unless clinical symptoms and plasma glucose levels > 11.1 mmol/L are present — in which case further testing is not required.
Always dip urine to check for ketones (if present, consider Type 1 diabetes or DKA).
ASYMPTOMATIC Patients
In the absence of symptoms — 2 abnormal results on separate days are required for the diagnosis.
Results interpretation:
- HbA1c > 48 mmol/mol → repeat HbA1c after 2 weeks → if HbA1c > 48 mmol/mol then code Diabetes and set recall
- HbA1c 42–47 mmol/mol → code and set “at risk of diabetes” recall
⚠️ Important Notes
- A diagnosis of diabetes has important legal and medical implications — be secure in the diagnosis
- A diagnosis should never be made on the basis of glycosuria
- A stick reading of finger prick should be confirmed by a venous sample, as per NICE guidelines
Using HbA1c in Diagnosing Diabetes
When HbA1c may not be accurate
HbA1c May NOT Be Accurate In:
- ALL symptomatic children and young people
- Symptoms suggesting Type 1 diabetes/pancreatic insufficiency (any age)
- Short duration diabetes symptoms
- Patient at high risk of diabetes who are acutely ill
- Taking medication that may cause rapid glucose rise (e.g., steroids, antipsychotics)
- Acute pancreatic damage/pancreatic surgery
- Patients with haemoglobinopathy — the labs test for this and will detect abnormalities
In these situations, use fasting glucose or OGTT instead.
Who to Screen
Risk-based screening for type 2 diabetes
Screen if:
- > 40 years of age with two or more of the following:
→ Family history in a first-degree relative
→ BMI > 25 (or > 23 for South Asian ethnicity)
→ South Asian ethnicity
Screening frequency: At least every 5 years with a fasting blood sugar or HbA1c.
Annual Screening Required For:
- Women with a history of gestational diabetes
- Hypertensives
- Patients with ischaemic heart disease, peripheral vascular disease, or stroke
Symptoms Requiring Testing:
- Polydipsia, polyuria/nocturia
- Weight loss & fatigue
- Recurrent UTIs
- Recurrent skin infections
- Recurrent thrush
- Neuropathic symptoms
- Changes in visual acuity
Referring to Hospital
Clear criteria for admission, same-day, and routine referrals
🚨 Immediate Hospital Admission
Admit to hospital if the person is at risk of a hyperglycaemic emergency:
- 🚩 Vomiting or abdominal pain
- 🚩 Reduced conscious level
- 🚩 Heavy ketonuria
- 🚩 Dehydration requiring IV fluids
- 🚩 Hypotension
- 🚩 Serious intercurrent problem
⚠️ Urgent Specialist Referral (within 2 weeks)
- Suspected Type 1 diabetes in adults (ketonuria, slim, rapid onset, weight loss)
- Diabetes in pregnancy — refer to joint obstetric/diabetes team
- Suspected MODY or secondary diabetes for genetic testing / specialist workup
- Rapidly declining renal function
📋 Routine Specialist Referral
- HbA1c persistently >75 mmol/mol despite optimised treatment
- Recurrent severe hypoglycaemia or hypoglycaemia unawareness
- Considering insulin therapy in primary care
- Complex comorbidities requiring specialist input
- eGFR <30 mL/min/1.73m² — refer to nephrology
- ACR >70 mg/mmol — refer to nephrology
✅ DIAGNOSIS CONFIRMED — CODE AND SET RECALL – REFER TO NURSE
(30 minute appointment)
- Make sure the diagnosis is correct! Remember LADA, MODY, Type 3c (ask diabetes GPSI if unsure)
- Code for QoF, SPECIFY TYPE OF DIABETES, promote to major problem and add to summary
- Set diabetes recall for 6 months
- Provide patient information PIL from patient.co.uk. Signpost to Diabetes UK website www.diabetes.org.uk
- Arrange referral (S1 word referrals): PRACTICE NURSE WILL COMPLETE THIS
☐ Annual retinal screening
☐ Annual diabetic podiatry check
☐ Dietician — getting started sessions
☐ Offer diabetes education programme (local scheme: DICE)
🟦 Pre-diabetes (HbA1c 42–47 mmol/mol) — Action Required
- Code as “at risk of diabetes” and set recall
- Refer to NHS Diabetes Prevention Programme (NHS DPP) for structured lifestyle intervention — this is a free, evidence-based programme shown to reduce progression to type 2 diabetes
- Advise on weight loss (5–10% target), diet, and physical activity
- Recheck HbA1c annually; earlier if new symptoms develop
📊 Monitoring and HbA1c Targets
Regular monitoring and individualised HbA1c targets are essential for optimal diabetes management and complication prevention.
Important: Individualised Targets
HbA1c targets should be individualised based on patient factors including age, comorbidities, hypoglycaemia risk, life expectancy, and patient preferences. Avoid a one-size-fits-all approach.
| Population | HbA1c Target | Clinical Note |
|---|---|---|
| Diet controlled | 48 mmol/mol | Lifestyle modification only |
| Single drug (not causing hypos) | 48 mmol/mol | e.g., metformin, DPP-4, SGLT-2 |
| Drug causing hypoglycaemia | 53 mmol/mol | Sulfonylurea or insulin |
| Frail/elderly/comorbidities | 58–64 mmol/mol | Avoid hypoglycaemia |
| Limited life expectancy | 64–75 mmol/mol | Symptom control priority |
| Type 1 diabetes | 48–53 mmol/mol | Individualise; consider Time in Range (TIR) if using CGM. Source: NICE NG17. |
Glycaemic Control and HbA1c Targets
Detailed guidance on target setting
Standard Targets
Diet controlled: HbA1c target 48 mmol/mol
On one drug not causing hypoglycaemia: HbA1c target 48 mmol/mol
On drug that may cause hypoglycaemia (e.g., sulfonylurea, insulin): HbA1c target 53 mmol/mol
🚨 BEWARE: Low HbA1c on Sulfonylurea or Insulin
If HbA1c is <48, and patient is on a SULFONYLUREA or INSULIN — ring and ask them if they are having HYPOs.
A “normal” HbA1c is NOT ideal for a patient on drugs that can cause hypos like insulin and sulfonylureas. Instead, aim for an HbA1c around 53.
When to Intensify Treatment
Consider intensifying drug treatment if HbA1c levels are not adequately controlled by a single drug and rise to:
- 58 mmol/mol or higher
Action: Add second-line agent, review lifestyle factors, check adherence
Relaxed Targets
Consider relaxing targets (e.g., to 64 mmol/mol or 8%) in patients with:
- Frailty or limited life expectancy
- High risk of hypoglycaemia
- Significant comorbidities
- Patient preference after discussion of risks/benefits
⚠️ Avoid Over-Treatment
Do NOT aim for HbA1c < 48 mmol/mol if on medications that can cause hypoglycaemia (sulfonylureas, insulin). Risk of severe hypos outweighs benefits of tight control.
Monitoring Frequency
HbA1c:
- Every 3–6 months (stable, on target)
- Every 3 months (treatment changes, not on target)
- More frequently if clinically indicated
Self-Monitoring Blood Glucose (SMBG):
- Type 1: Multiple times daily
- Type 2 on insulin: As advised by diabetes team
- Type 2 on oral agents: Not routinely recommended unless specific indication
Blood Glucose Targets
Type 1 Diabetes:
- Fasting: 5–7 mmol/L
- Before meals: 4–7 mmol/L
- 2 hours post-meal: 5–9 mmol/L
- Bedtime: 5–7 mmol/L
Type 2 Diabetes (if monitoring):
- Fasting: 4–7 mmol/L
- 2 hours post-meal: <8.5 mmol/L
🧓 Glycaemic Targets in Special Populations
Frailty, Functional Dependency, Dementia & End of Life — individualised targets are essential
⚠️ GP Principle: Exempt from Standard QoF Targets
If you use relaxed HbA1c targets for any of the groups below, exempt the patient from standard QoF targets and document your clinical rationale clearly in the notes.
| Population | HbA1c Target | Definition / Tool |
|---|---|---|
| Functionally Dependent | 53–64 mmol/mol | Loss of ADL function; requires additional medical or social care |
| Frail | 60–70 mmol/mol | Significant fatigue, weight loss, reduced mobility, falls risk — Clinical Frailty Scale |
| Dementia | 60–70 mmol/mol | Significant memory/orientation problems, unable to self-care — MiniCog tool |
| End of Life (life expectancy <1 year) | Avoid symptoms | Goal: prevent symptomatic hypos and hyperglycaemia — HbA1c less useful; use glucose levels |
📋 Clinical Frailty: Key Points
- Frailty affects ~25% of older people with diabetes and is independently associated with hypoglycaemia risk
- Assess using Clinical Frailty Scale (CFS) or PRISMA-7 questionnaire
- Assess for frailty in any person with diabetes aged ≥65 years
- A declining HbA1c without any treatment change may signal deterioration — investigate
- In frail patients, avoid sulfonylureas and insulin unless essential — hypo risk is amplified
- Consider deprescribing glucose-lowering agents if HbA1c falls below target range
🧠 Dementia & Diabetes: Specific Risks
- Hypoglycaemia in dementia may present as uncharacteristic behaviour — easily missed
- Patients with dysphasia cannot reliably report hypo symptoms
- Prioritise hypo prevention above glycaemic targets
- Review medications — consider stopping agents that increase hypo risk
🚨 End of Life: Simplify Treatment
- If appetite is reduced / weight falling: GLP-1 RA and SGLT-2 inhibitors often inappropriate — stop them
- If maintaining hydration is difficult: diuretic agents (e.g., SGLT-2 inhibitors) may be inappropriate
- Aim to keep patient free of symptomatic hyperglycaemia and hypoglycaemia — minimise monitoring burden
- Document a revised glycaemic care plan in the notes and ensure this is communicated to all involved carers
📡 Continuous Glucose Monitoring (CGM)
Sensor-based glucose monitoring for improved diabetes management
Who Should Use CGM?
- Type 1 diabetes: All adults — CGM (e.g., FreeStyle Libre, Dexcom G6/G7) is recommended per NICE NG17 and technology appraisals
- Type 2 diabetes on insulin: Consider CGM where frequent hypoglycaemia or suboptimal control
- Specialist diabetes team to initiate and support CGM use
Benefits of CGM:
- Provides Time in Range (TIR) data (target: >70% time in 3.9–10 mmol/L)
- Reduces hypoglycaemia episodes and unawareness
- Improves HbA1c without increasing hypo risk
- Reduces need for finger-prick testing
- Trend arrows guide real-time insulin decisions
GP Role in CGM:
- Prescribe sensor supplies on FP10 once initiated by specialist team
- Ensure patient is trained and supported
- Review TIR data at annual review alongside HbA1c
- Refer to diabetes team if having difficulty with device use
- CGM does not replace HbA1c in patients with haemoglobinopathy
⚠️ Complications of Diabetes
Diabetes complications are classified as microvascular (retinopathy, nephropathy, neuropathy) and macrovascular (cardiovascular, cerebrovascular, peripheral arterial disease). Early detection and management are crucial.
- RENAL — Nephropathy (microalbuminuria → CKD → ESRD)
- EYES — Retinopathy (leading cause of blindness in working-age adults)
- FEET — Neuropathy, ulcers, peripheral arterial disease, amputation risk
- HEART — Cardiovascular disease (leading cause of death in diabetes)
Diabetic Retinopathy
Leading cause of blindness in working-age adults. Caused by damage to retinal blood vessels.
Screening:
Annual digital retinal photography for all people with diabetes. Refer urgently if proliferative changes or maculopathy detected.
Management:
Optimise glycaemic control, BP control, laser photocoagulation, anti-VEGF injections for maculopathy (specialist-led).
Diabetic Nephropathy
Progressive kidney damage leading to CKD and potential ESRF. Affects 20–40% of people with diabetes.
Screening:
Annual ACR (albumin:creatinine ratio) and eGFR. Microalbuminuria (ACR 3–30 mg/mmol) indicates early nephropathy.
Management:
ACE inhibitor or ARB (even if normotensive), BP <130/80, optimise glycaemic control, SGLT-2 inhibitor for renoprotection.
💊 ACE Inhibitor / ARB Dosing for Nephropathy (Source: BNF)
| Drug | Class | Starting Dose | Maintenance | Notes |
|---|---|---|---|---|
| Ramipril | ACE inhibitor (first-line) | 2.5 mg OD | 5–10 mg OD | Monitor U&Es and creatinine 1–2 weeks after starting. Avoid in pregnancy. |
| Lisinopril | ACE inhibitor (alternative) | 2.5–5 mg OD | 10–20 mg OD | Monitor U&Es. Avoid if ACE-inhibitor cough — switch to ARB. |
| Losartan | ARB (if ACE-I not tolerated) | 50 mg OD | 50–100 mg OD | Use if ACE-I cough. Monitor U&Es. Avoid in pregnancy. |
| Candesartan | ARB (alternative) | 4–8 mg OD | 8–32 mg OD | Alternative ARB. Monitor U&Es and BP. |
Do not combine ACE inhibitor with ARB. Duration: long-term, review annually. SGLT-2 inhibitors (e.g. dapagliflozin 10 mg OD) provide additional renoprotection — see Pharmacological Treatment section.
Diabetic Neuropathy
Nerve damage affecting peripheral, autonomic, and focal nerves. Affects up to 50% of people with diabetes.
Screening:
Annual foot examination: 10g monofilament, vibration sense, ankle reflexes. Ask about symptoms (pain, tingling, numbness).
Management:
Optimise glycaemic control. For neuropathic pain: pharmacological treatment as below. Foot care education.
💊 Neuropathic Pain — Drug Treatment (Source: NICE NG173)
First-line options (any one of the following — choose based on patient factors, comorbidities, other medications):
| Drug | Starting Dose | Titration / Max Dose | Duration to assess | Notes |
|---|---|---|---|---|
| Duloxetine (SNRI — licensed for diabetic peripheral neuropathic pain) | 60 mg OD | Max 120 mg/day (in 2 divided doses) | 8 weeks | Preferred first-line for diabetic neuropathic pain. Avoid in severe renal impairment (eGFR <30). Taper on stopping. |
| Amitriptyline (TCA — off-label for neuropathic pain) | 10 mg nocte | Titrate by 10–25 mg every 2–4 weeks; max 75 mg nocte | 12 weeks | Causes sedation — take 1–2 hours before bed. Caution in elderly, cardiac disease, glaucoma, prostatic hypertrophy. Check anticholinergic burden. |
| Pregabalin (Controlled Drug — Schedule 3) | 75 mg BD (or 25 mg BD if elderly/renal impairment) | Titrate every 3–7 days; max 600 mg/day | 8 weeks | Schedule 3 CD — 28-day prescriptions. Monitor for abuse potential. Dose reduction needed if eGFR <60. |
| Gabapentin (Controlled Drug — Schedule 3) | 300 mg OD (day 1), 300 mg BD (day 2), 300 mg TDS (day 3) | Titrate by 300 mg every 2–3 days; max 3600 mg/day in 3 divided doses | 8 weeks | Schedule 3 CD — 28-day prescriptions. Dose reduction needed in renal impairment. Monitor for abuse potential. |
If monotherapy inadequate, consider combination (e.g., duloxetine + pregabalin) after specialist review. Do not combine gabapentin and pregabalin. Refer to pain specialist if not controlled in primary care.
Diabetic Foot Disease
Combination of neuropathy, ischaemia, and infection. Leading cause of non-traumatic lower limb amputation.
Screening:
Annual foot check: inspection, pulses, sensation, deformities. Risk stratify (low/moderate/high). Refer high-risk to podiatry.
Management:
Foot care education, appropriate footwear, regular podiatry. Urgent referral for ulcers/infection. Multidisciplinary foot team.
Cardiovascular Disease
People with diabetes have 2–4× increased risk of MI and stroke. CVD is the leading cause of death in diabetes.
Screening:
Annual BP, lipids, cardiovascular risk assessment (QRISK3). ECG if symptomatic or high risk.
Management:
Atorvastatin 20 mg OD (primary prevention) or 80 mg OD (secondary prevention). BP <140/80. Antiplatelet therapy only for established CVD — not for primary prevention in diabetes. Optimise glycaemic control. Source: NICE NG238 / NG28.
Cerebrovascular Disease
Increased risk of stroke and TIA. Diabetes doubles stroke risk.
Screening:
Annual BP, cardiovascular risk assessment. Ask about TIA symptoms.
Management:
BP control, statin therapy, antiplatelet therapy (aspirin 75 mg OD) if previous ischaemic CVD event, smoking cessation.
Peripheral Arterial Disease
Reduced blood flow to limbs. Increases risk of foot ulcers and amputation.
Screening:
Annual foot pulses, ABPI if symptomatic or absent pulses. Ask about claudication.
Management:
Smoking cessation, supervised exercise, statin therapy, antiplatelet therapy. Refer vascular surgery if severe or critical limb ischaemia.
👁️ Eyes
- Sudden vision loss — same-day ophthalmology
- Severe or proliferative retinopathy on screening
- Maculopathy detected at screening
- Vitreous haemorrhage
🫘 Kidneys
- eGFR drop >15 mL/min/1.73m² in 1 year — refer nephrology
- eGFR <30 mL/min/1.73m² — refer nephrology
- ACR >70 mg/mmol — refer nephrology
- Nephrotic syndrome (heavy proteinuria, oedema, hypoalbuminaemia)
🦶 Feet
- New foot ulcer — urgent MDT foot team referral within 24h if infected or ischaemic
- Signs of infection: cellulitis, osteomyelitis, deep-space infection
- Critical limb ischaemia: rest pain, gangrene, pallor on elevation
- Active Charcot foot: hot, swollen, deformed foot — do not weight-bear
❤️ Heart & Vessels
- Acute coronary syndrome — 999
- Acute heart failure
- Stroke or TIA — immediate stroke pathway (FAST)
- Peripheral arterial disease with critical ischaemia
🥗 Lifestyle Management
Lifestyle modification is the cornerstone of type 2 diabetes management. Diet, exercise, and weight loss can significantly improve glycaemic control and reduce cardiovascular risk.
Dietary Advice
Key Principles:
- Carbohydrate quality: Choose low GI carbs (wholegrain, vegetables, legumes)
- Portion control: Use plate method (½ vegetables, ¼ protein, ¼ carbs)
- Reduce sugar: Avoid sugary drinks, sweets, processed foods
- Healthy fats: Olive oil, nuts, oily fish. Limit saturated fat
- Fibre: Aim for 30 g/day (vegetables, wholegrains, legumes)
- Regular meals: Avoid skipping meals, especially if on insulin/sulfonylureas
Referral: All newly diagnosed people with diabetes should be offered dietician review and structured education programme (e.g., DESMOND for Type 2, DAFNE for Type 1).
Physical Activity
Recommendations:
- Aerobic exercise: 150 minutes/week moderate intensity (brisk walking, cycling, swimming)
- Resistance training: 2–3 sessions/week (weights, resistance bands)
- Reduce sedentary time: Break up sitting every 30 minutes
- Start gradually: Build up slowly if previously inactive
Benefits of Exercise:
- Improves insulin sensitivity
- Lowers blood glucose
- Aids weight loss
- Reduces cardiovascular risk
- Improves mood and wellbeing
Weight Management
Weight Loss Benefits:
- 5–10% weight loss significantly improves glycaemic control
- May achieve remission of type 2 diabetes (especially if recent diagnosis)
- Reduces need for medications
- Improves cardiovascular risk factors
Strategies:
- Calorie deficit (500–600 kcal/day reduction)
- Consider very low calorie diet (VLCD) programmes (e.g., DiRECT trial protocol)
- Behavioural support and goal setting
- Regular monitoring and follow-up
- Consider bariatric surgery if BMI >35 with inadequate control
Smoking Cessation
Smoking and Diabetes:
Smoking significantly increases risk of cardiovascular disease, nephropathy, retinopathy, and peripheral vascular disease in diabetes. Smoking cessation is one of the most important interventions.
Support Options:
- Refer to NHS Stop Smoking Service
- Nicotine replacement therapy (NRT) — patches, gum, lozenge, inhalator, mouth spray
- Varenicline (Champix) — see doses below
- Bupropion (Zyban) — see doses below
- Behavioural support and counselling
- Regular follow-up and encouragement
💊 Smoking Cessation Pharmacotherapy Doses (Source: BNF / NICE CKS Smoking Cessation)
| Drug | Dose & Regimen | Duration | Notes |
|---|---|---|---|
| Nicotine Replacement Therapy (NRT) Multiple forms: patch, gum, lozenge, inhalator, mouth spray | Dose varies by product and smoking heaviness. E.g., 21 mg/24-hour patch for heavy smokers (>10/day); reduce to lower-strength patches over 12 weeks. Combination NRT (patch + fast-acting form) is more effective than single product. | 8–12 weeks; can extend to 24 weeks if needed | Available OTC. Can be prescribed. Safe in stable cardiovascular disease. |
| Varenicline (Champix) | Days 1–3: 0.5 mg OD. Days 4–7: 0.5 mg BD. Week 2 onwards: 1 mg BD. Set quit date after 1–2 weeks of treatment. | 12 weeks (extend to 24 weeks if successful at 12 weeks) | Most effective single agent. Monitor for mood change, suicidal ideation. Caution in severe renal impairment. Reduce dose to 0.5 mg BD if eGFR <30. |
| Bupropion (Zyban) | 150 mg OD for 6 days, then 150 mg BD. Set quit date in week 2. | 7–9 weeks total | Lowers seizure threshold — contraindicated in seizure disorders, eating disorders, recent MAOI use, abrupt alcohol/benzodiazepine withdrawal. Do not combine with varenicline. |
🍺 Alcohol and Diabetes
Alcohol guidance for people with diabetes
Key Risks of Alcohol in Diabetes
- Hypoglycaemia risk: Alcohol inhibits hepatic gluconeogenesis — can cause hypoglycaemia hours after drinking, especially with insulin or sulfonylureas
- Hypoglycaemia can be masked by intoxication and mistaken for drunkenness — always wear a medical ID
- Alcohol adds hidden calories — contributes to weight gain and poor glycaemic control
- Binge drinking can cause triglyceride elevation and pancreatitis
Safe Limits & Advice:
- No more than 14 units per week, spread over 3 or more days
- Avoid binge drinking (more than 6 units in one session)
- Have at least 2 alcohol-free days per week
- Always eat carbohydrate when drinking to reduce hypo risk
- Never drink on an empty stomach if on insulin or sulfonylureas
Clinical Actions:
- Screen for alcohol misuse using AUDIT-C at annual review
- Brief intervention if AUDIT-C positive
- Refer to alcohol services if dependent drinking suspected
- Document alcohol use in notes
- Advise on hypo risk at night if drinking in evening — check glucose before bed
💊 Pharmacological Treatment
NICE NG28 (updated February 2026) recommends SGLT-2 inhibitors alongside modified-release metformin as first-line treatment for most newly diagnosed type 2 diabetes patients. This represents a major shift in UK diabetes management.
Diabetes Management Overview
Comprehensive approach to diabetes care
Lifestyle
- Diet and exercise advice
- Weight management
- Smoking cessation
Blood Pressure
- Target: <140/80 mmHg (or <130/80 if end-organ damage)
- ACE inhibitor or ARB first-line (e.g., ramipril 2.5–10 mg OD)
Lipids
- Atorvastatin 20 mg OD for primary prevention
- Atorvastatin 80 mg OD for secondary prevention
Microalbuminuria
- ACE inhibitor or ARB regardless of BP
- Reduces progression to nephropathy
Antiplatelets
- Aspirin 75 mg OD for secondary prevention only
- Not recommended for primary prevention in diabetes
Which Medication and When?
Treatment algorithm for type 2 diabetes — NICE NG28 (February 2026)
Step 1: First-Line Treatment
Modified-release metformin + SGLT-2 inhibitor (dapagliflozin or empagliflozin) for most patients
Personalise based on: heart failure, atherosclerotic CVD, early onset, obesity, CKD, frailty. Introduce one medicine at a time. Check renal and cardiac status before starting SGLT-2 inhibitor.
Step 2: Dual Therapy
If HbA1c remains >58 mmol/mol after 3 months:
- Add DPP-4 inhibitor (e.g., sitagliptin 100 mg OD)
- OR Pioglitazone 15–30 mg OD (if not at risk of fractures/bladder cancer/heart failure)
- OR Sulfonylurea (e.g., gliclazide — if rapid glucose control needed)
Step 3: Triple Therapy
If HbA1c remains >58 mmol/mol:
- Add third oral agent from different class
- OR consider GLP-1 receptor agonist (specialist-initiated) if BMI >35 kg/m² or obesity-related comorbidities
Step 4: Insulin Therapy
If HbA1c remains >58 mmol/mol despite triple therapy:
- Refer to specialist diabetes team for insulin initiation
- Continue metformin + SGLT-2 inhibitor where appropriate
Mechanism of Action:
Reduces hepatic glucose production, increases insulin sensitivity in peripheral tissues, delays glucose absorption from gut. Does not cause hypoglycaemia alone.
Dosing (Source: BNF / NICE NG28)
Modified-release (MR) — preferred: Start 500 mg OD with evening meal; increase by 500 mg every 2 weeks as tolerated; maximum 2000 mg OD.
Standard-release (if MR not appropriate): Start 500 mg OD or BD with meals; increase weekly; usual maximum 1 g BD (max 3 g/day in divided doses if tolerated).
MR formulation associated with lower GI side effects and better adherence. Those stable on standard-release can continue.
Side Effects:
- GI upset (nausea, diarrhoea) — usually settles after 1–2 weeks; less with MR formulation
- Lactic acidosis (rare but serious) — risk increased in renal impairment, hypoxia
- Vitamin B12 deficiency with long-term use — check B12 every 1–2 years
Contraindications / Dose Reduction:
- eGFR <30 mL/min/1.73m² — STOP
- eGFR 30–44: maximum dose 1000 mg daily
- eGFR 45–59: maximum dose 2000 mg daily
- Severe tissue hypoxia (MI, sepsis, heart failure), acute kidney injury — STOP
Mechanism of Action:
Inhibit renal SGLT-2 glucose reabsorption, causing glycosuria. Lower blood glucose independent of insulin. Also have cardiovascular and renal protective mechanisms beyond glucose lowering.
Dosing (Source: BNF)
Dapagliflozin (Forxiga): 10 mg OD (take in the morning). Not to be used if eGFR <45 for glucose-lowering effect (can continue for CV/renal protection at lower eGFR — see BNF).
Empagliflozin (Jardiance): 10 mg OD (take in the morning); can increase to 25 mg OD for additional benefit in established ASCVD.
Generic dapagliflozin now available — preferred due to cost. Duration: long-term.
Benefits:
- Cardiovascular benefits (reduced MI, stroke, CV death) in established CVD
- Renoprotective (slows CKD progression)
- Weight loss (~2–3 kg)
- BP reduction (~3–5 mmHg)
- No hypoglycaemia risk when used without insulin/sulfonylurea
Side Effects & Cautions:
- Genital thrush / recurrent UTIs (advise hygiene; treat as usual)
- Euglycaemic DKA (rare but serious — stop before surgery/prolonged fasting)
- Dehydration, postural hypotension (review diuretics)
- Fournier's gangrene (rare — seek urgent review if perineal pain/swelling)
ℹ️ Specialist-Initiated Medication
GLP-1 receptor agonists are typically initiated by a specialist diabetes team in the UK. Specific doses and titration schedules are determined by the specialist. GPs may continue and monitor treatment once established.
Mechanism of Action:
Mimic incretin hormones. Increase insulin secretion (glucose-dependent), suppress glucagon, slow gastric emptying, reduce appetite and weight.
When Considered (NICE NG28 2026):
- Step 3/4 if BMI >35 kg/m² or obesity-related comorbidities
- Established ASCVD or heart failure with reduced ejection fraction
- Significant weight loss goal alongside diabetes management
Benefits:
- Significant weight loss (5–10+ kg with semaglutide)
- Cardiovascular benefits in established ASCVD
- No hypoglycaemia risk when used alone
- Once-weekly subcutaneous injection available (semaglutide, dulaglutide)
Common Side Effects:
- Nausea, vomiting (common initially, usually settles with titration)
- Diarrhoea, constipation
- Pancreatitis (rare — warn patient re: severe abdominal pain)
- Injection site reactions
Mechanism of Action:
Inhibit DPP-4 enzyme, increasing incretin hormone (GLP-1, GIP) levels. Increase glucose-dependent insulin secretion and decrease glucagon. Weight neutral.
Dosing (Source: BNF)
Sitagliptin (Januvia): 100 mg OD. Reduce to 50 mg OD if eGFR 30–49; 25 mg OD if eGFR <30.
Linagliptin (Trajenta): 5 mg OD. No dose adjustment needed in renal impairment — useful if eGFR low.
Alogliptin (Vipidia): 25 mg OD. Reduce to 12.5 mg OD if eGFR 30–59; 6.25 mg OD if eGFR <30.
All taken orally once daily. Duration: long-term.
Benefits:
- Well tolerated, weight neutral
- No hypoglycaemia risk when used without insulin/sulfonylurea
- Once-daily dosing; most safe in renal impairment (especially linagliptin)
Side Effects:
- Generally well tolerated
- Pancreatitis (rare — warn patient; stop if severe abdominal pain)
- Upper respiratory tract infections, nasopharyngitis
Mechanism of Action:
Stimulate insulin secretion from pancreatic beta cells. Glucose-independent action — hence risk of hypoglycaemia even if blood glucose is normal.
Dosing (Source: BNF)
Gliclazide (standard-release): Initially 40–80 mg OD with breakfast. Adjust every 4–6 weeks according to response. Doses up to 160 mg can be given as a single dose; doses above 160 mg are given in divided doses (e.g., 80 mg BD). Maximum 320 mg/day.
Gliclazide MR (modified-release, once-daily): Initially 30 mg OD with breakfast; maximum 120 mg OD.
Glimepiride: Initially 1 mg OD with first main meal; usual maintenance 1–4 mg OD; maximum 6 mg OD.
Benefits:
- Rapid glucose lowering — useful for symptomatic hyperglycaemia
- Inexpensive; once or twice daily dosing
- Long clinical track record
Side Effects & Cautions:
- Hypoglycaemia (major risk — especially in elderly, renal impairment, irregular meals)
- Weight gain (~2–3 kg)
- Caution in renal impairment: use with care; avoid if eGFR <30
- HbA1c target if on sulfonylurea: do not aim below 53 mmol/mol — risk of symptomatic hypoglycaemia
Mechanism of Action:
PPAR-gamma agonist. Increases insulin sensitivity in muscle and adipose tissue. Reduces hepatic glucose production.
Dosing (Source: BNF)
Pioglitazone: Initially 15–30 mg OD. Increase to maximum 45 mg OD according to response. Take at the same time each day, with or without food.
Start at 15 mg OD in elderly or those at risk of fluid retention. Duration: long-term; review efficacy and safety annually.
Benefits:
- No hypoglycaemia risk (when used without insulin/sulfonylurea)
- Durable glucose lowering
- May improve lipid profile (raises HDL)
Contraindications & Side Effects:
- Heart failure or history of heart failure — CONTRAINDICATED
- Weight gain (3–4 kg), fluid retention, oedema
- Increased fracture risk (especially postmenopausal women)
- Small increased risk of bladder cancer with prolonged use — avoid if history of bladder cancer
ℹ️ Specialist-Initiated Medication
Insulin initiation in type 2 diabetes should involve the specialist diabetes team. Specific insulin type, dose, and titration schedule are determined by the specialist. Note: Levemir (insulin detemir) is being discontinued (expected end 2026) — patients will need switching to an alternative basal insulin.
Types:
- Basal (long-acting): Insulin glargine (Lantus, Toujeo), insulin degludec (Tresiba) — once daily
- Bolus (rapid-acting): Insulin aspart (NovoRapid), insulin lispro (Humalog) — with meals
- Mixed: Combination — twice daily
- Consider biosimilar insulins for new initiations (cost saving).
GP Role:
- Continue metformin (± SGLT-2 inhibitor) when insulin started
- Monitor HbA1c every 3–6 months, adjust dose per specialist guidance
- Sick day rules — educate patients
- Driving licence notification (DVLA) if on insulin
- Issue glucagon emergency kit where appropriate
Side Effects:
- Hypoglycaemia (major risk — educate patient and family)
- Weight gain (2–4 kg)
- Lipohypertrophy at injection sites — rotate sites
Watch Out for Metformin and eGFR
Critical guidance on metformin dosing in renal impairment — Source: BNF / NICE NG28
🚫 STOP Metformin if:
- eGFR <30 mL/min/1.73m² — STOP metformin immediately
- Acute kidney injury or severe dehydration
- Severe tissue hypoxia (e.g., sepsis, MI, heart failure)
⚠️ REDUCE Dose if:
- eGFR 30–44 mL/min/1.73m² — Maximum dose 1000 mg daily (500 mg BD)
- eGFR 45–59 mL/min/1.73m² — Maximum dose 2000 mg daily (1000 mg BD or MR 2000 mg OD)
✅ SAFE if:
eGFR ≥60 mL/min/1.73m² — Standard dosing up to 2000 mg/day MR (or up to 3 g/day standard-release)
📋 Monitoring Requirements:
- Check eGFR at least annually in all patients on metformin
- Check eGFR every 3–6 months if eGFR <60 mL/min/1.73m²
- Review metformin dose whenever eGFR changes
- Advise patients to STOP metformin during acute illness (sick day rules)
💡 GP Pearl: “Set up a search for all patients with diabetes on metformin with eGFR <45 — many will need dose reduction or stopping. This is a common cause of lactic acidosis admissions. Add eGFR to your diabetes annual review template.”
⚠️ Safety Alert: SGLT-2 Inhibitors and Euglycaemic DKA
A serious but preventable complication — check ketones, not just glucose
What Is Euglycaemic DKA?
SGLT-2 inhibitors can cause diabetic ketoacidosis even with near-normal blood glucose levels (typically 8–14 mmol/L). This makes it easy to miss. The glucose is lower because the drug continues to cause urinary glucose excretion — but ketone production is unchecked.
Key rule: if a patient on a flozin is unwell — check ketones first, not just glucose.
Risk Factors for Euglycaemic DKA:
- Acute illness, infection, surgery, trauma
- Reduced food intake or prolonged fasting
- Dehydration
- Alcohol excess
- Insulin dose reduction or omission
- Very low carbohydrate diet
- Undiagnosed Type 1 diabetes prescribed an SGLT-2 inhibitor
✅ Action:
- Stop SGLT-2 inhibitor during any acute illness (sick day rules)
- Stop before elective surgery (withhold 3 days before planned procedure)
- Check blood or urine ketones if patient is unwell — do not rely on glucose alone
- Immediate hospital referral if DKA suspected (ketones >3 mmol/L or ketones ++ on urine dip)
- Educate patients: carry a SGLT-2 inhibitor sick day rules card (available from TREND-UK)
⚖️ Health Inequalities in Diabetes Prescribing
Actively address inequalities in access to evidence-based treatments
Who Is Being Under-Treated?
Despite clear evidence of cardiovascular and renal benefit, SGLT-2 inhibitors and GLP-1 receptor agonists are significantly under-prescribed to:
- Women — despite equivalent benefit
- Older patients — despite high cardiovascular risk
- Black, Asian, and minority ethnic patients — who often have higher disease burden
- People in deprived areas — where diabetes prevalence is higher
💡 What You Can Do:
- Proactively review all eligible patients for SGLT-2 inhibitor prescription at each diabetes review
- Do not let implicit assumptions about age, sex, or ethnicity influence prescribing decisions
- Use your practice QOF and audit data to identify demographic gaps in treatment
- Offer shared decision-making, ensuring all patients understand the cardiovascular and renal benefits
- Offer patient materials in appropriate languages via Diabetes UK
🚨 Acute Emergencies
Diabetic emergencies require immediate recognition and management. DKA, HHS, and severe hypoglycaemia are life-threatening conditions requiring urgent hospital admission.
- Hyperglycaemia — blood glucose >11 mmol/L (or known diabetes)
- Acidosis — pH <7.3 or bicarbonate <15 mmol/L
- Ketonaemia — blood ketones >3 mmol/L (or urine ketones 2+)
Diabetic Ketoacidosis (DKA)
Diagnostic Criteria (all 3 required — HAK):
- Blood glucose >11 mmol/L (or known diabetes)
- Blood ketones >3 mmol/L (or urine ketones ++)
- pH <7.3 or bicarbonate <15 mmol/L
Clinical Features:
- Polyuria, polydipsia, weight loss
- Nausea, vomiting, abdominal pain
- Kussmaul breathing (deep, rapid)
- Acetone breath (pear-drops smell)
- Dehydration, hypotension
- Confusion, drowsiness, coma
Management:
- Immediate hospital admission
- IV fluids (0.9% saline) — hospital-led
- Fixed-rate IV insulin infusion — hospital-led
- Potassium replacement — hospital-led
- Treat underlying cause (infection, MI, non-adherence)
⚠️ High-Risk Features in DKA (indicate ICU/HDU):
- pH <7.0
- Bicarbonate <5 mmol/L
- Potassium <3.5 mmol/L on admission
- GCS <12
- Oxygen saturation <92% on air
- Systolic BP <90 mmHg
Hyperosmolar Hyperglycaemic State (HHS)
Diagnostic Criteria:
- Blood glucose >30 mmol/L
- Serum osmolality >320 mOsm/kg
- No significant ketones or acidosis
- Typically insidious onset over days/weeks
Clinical Features:
- Severe dehydration (may lose 10–15 L fluid)
- Confusion, drowsiness, coma
- Focal neurological signs
- Seizures
- Usually in elderly patients with type 2 diabetes
- High mortality (15–20%)
Management:
- Immediate hospital admission
- IV fluids (0.9% saline) — slower than DKA; hospital-led
- Low-dose IV insulin (if glucose not falling with fluids) — hospital-led
- Thromboprophylaxis (very high VTE risk)
- Treat underlying cause
⚠️ High-Risk Features in HHS:
- Osmolality >350 mOsm/kg
- Sodium >160 mmol/L
- GCS <12
- Seizures
- Acute kidney injury
- Age >70 years with comorbidities
Severe Hypoglycaemia
Definition:
Blood glucose <4 mmol/L with symptoms, or <3 mmol/L regardless of symptoms. Severe hypoglycaemia = requiring external assistance.
Clinical Features:
Autonomic symptoms:
- Sweating, tremor
- Palpitations
- Hunger
- Anxiety
Neuroglycopenic symptoms:
- Confusion, drowsiness
- Difficulty concentrating
- Slurred speech
- Seizures, coma
- Behavioural change, aggression (can mimic stroke)
Management:
Conscious and Able to Swallow:
- 15–20 g fast-acting carbohydrate (200 ml Lucozade, 4–5 glucose tablets, 200 ml fruit juice, 5 jelly babies)
- Wait 15 minutes, recheck glucose
- If still <4 mmol/L, repeat
- Follow with 10–20 g longer-acting carbohydrate (sandwich, biscuits)
Unconscious or Unable to Swallow:
- DO NOT give anything by mouth
- Recovery position
- Glucagon 1 mg IM (if available and trained) — or glucagon nasal powder (Baqsimi) 3 mg if preferred
- Call 999
- Hospital: IV glucose 10% 150–200 ml over 15 minutes
⚠️ High-Risk Hypoglycaemia Features — Refer/Investigate:
- Recurrent severe hypoglycaemia
- Impaired awareness of hypoglycaemia (hypoglycaemia unawareness)
- Nocturnal hypoglycaemia
- Patient drives or operates machinery
- Hypoglycaemia after sulfonylurea — may be prolonged; admit for observation
📞 When to Call 999
Situations requiring immediate emergency ambulance
- Suspected DKA or HHS
- Severe hypoglycaemia not responding to treatment after two attempts
- Unconscious or fitting
- Severe dehydration or confusion
- Chest pain or acute breathlessness
- Signs of stroke or TIA (FAST: Face, Arms, Speech, Time)
🤒 Sick Day Rules & SADMAN
When patients with diabetes become acutely unwell, certain medications must be withheld to prevent serious complications including AKI and euglycaemic DKA. Every patient on these medications should be counselled proactively.
- SGLT-2 inhibitors — medicines ending in “flozin” (e.g., empagliflozin, dapagliflozin, canagliflozin)
- ACE inhibitors — medicines ending in “pril” (e.g., ramipril, lisinopril, perindopril)
- Diuretics — medicines ending in “ide” (e.g., furosemide, bendroflumethiazide, bumetanide)
- Metformin
- ARBs — medicines ending in “sartan” (e.g., losartan, candesartan, valsartan)
- NSAIDs — anti-inflammatory painkillers (e.g., ibuprofen, diclofenac, naproxen)
When to Apply Sick Day Rules
Situations requiring medication withholding
🚨 STOP SADMAN Medications If:
- Vomiting or diarrhoea (unless only minor and mild)
- Fevers, sweats, and shaking (e.g., infections including chest or urinary)
- Unable to eat or drink normally
- Any illness causing significant dehydration
✅ When to Restart
- Restart these medicines when the patient is well again
- After 24–48 hours of eating and drinking normally
- If unsure: contact pharmacist, GP nurse, or call 111
📄 GP Teaching Point
- Document sick day rules counselling in the patient record
- Advise at diagnosis and reinforce at annual review
- Provide written information — consider TREND-UK sick day card
- Advise patients to inform family members of these rules
General Advice When Unwell
Patient self-management guidance during illness
- Rest and maintain fluid intake
- Drink plenty of sugar-free fluids — aim for at least 3 litres (5 pints) a day, unless the patient has heart failure (in which case follow heart failure fluid restriction guidance)
- Try to maintain a normal meal pattern; if unable, replace meals with carbohydrate-containing snacks or drinks (yoghurt, milk, fruit juice, flat Lucozade)
- Avoid excessive caffeine (dehydrating)
- Take paracetamol as needed for pain or fever — avoid NSAIDs
- Seek advice about antibiotics if infection suspected
- If vomiting uncontrollably, contact GP or call 111
⚠️ Patients on Insulin
- Keep taking insulin even if not eating
- Test blood glucose 4 or more times per day when unwell
- If Type 1 diabetes and blood glucose ≥15 mmol/L or ≥2% glucose in urine: test for ketones
- If urine or blood ketones positive: contact GP or diabetes team immediately
⚠️ Ketone Testing During Illness
Particularly important for patients with Type 1 diabetes
When diabetes goes out of control during severe illness, it can progress to diabetic ketoacidosis (DKA). Ketones are an early warning sign.
Test for Ketones If:
- Type 1 diabetes and blood glucose ≥ 15 mmol/L, or
- Two per cent or more glucose in urine, or
- Vomiting and feeling significantly worse
If ketone test is positive → contact GP or diabetes care team immediately.
For patients with SGLT-2 inhibitors: euglycaemic DKA can occur with normal blood glucose — ketone testing is essential even if BG appears normal.
📋 Annual Reviews and Care Processes
NICE recommends 9 care processes as part of the annual diabetes review. Completing all 9 processes is associated with reduced complications and improved outcomes.
- HbA1c — glycaemic control
- BP — blood pressure
- CHOL — cholesterol
- RENAL — kidney function (creatinine, eGFR, ACR)
- FEET — foot examination
- EYES — retinal screening
- BMI — body mass index
- SMOKE — smoking status
The Annual Diabetic Review
Comprehensive checklist for annual diabetes assessment
📋 Annual Review Checklist
☐ HbA1c — target individualised
☐ Blood pressure — target <140/80 mmHg (or <130/80 if end-organ damage)
☐ Cholesterol — total cholesterol <5 mmol/L, LDL <3 mmol/L (or <2 if CVD)
☐ Serum creatinine & eGFR — check renal function
☐ Urinary albumin — ACR for microalbuminuria screening
☐ Foot examination — neuropathy, pulses, ulcers
☐ Retinal screening — annual digital photography
☐ BMI — weight management advice
☐ Smoking status — cessation advice if applicable
💊 Medication Review
- Review all diabetes medications — doses, adherence, side effects
- Check for drug interactions
- Review metformin dose if eGFR <60 mL/min/1.73m²
- Ensure on appropriate cardiovascular protection (statin, ACE-I/ARB if indicated)
🎯 Targets at a Glance
HbA1c
48–53 mmol/mol
BP
<140/80 mmHg
Total Chol
<5 mmol/L
📝 Documentation
- Record all 9 care processes in patient notes
- Document any referrals made (retinopathy, podiatry, dietician)
- Update diabetes register and QOF data
- Provide patient with written summary of review and targets
Measure HbA1c every 3–6 months (more frequently if treatment changes or not on target). Individualise targets based on patient factors.
Target HbA1c:
- 48 mmol/mol — diet controlled or single drug not causing hypos
- 53 mmol/mol — on drug causing hypoglycaemia (sulfonylurea, insulin)
- 58–64 mmol/mol — frail/elderly/comorbidities
🚨 BEWARE: Low HbA1c on Sulfonylurea or Insulin
If HbA1c is <48, and patient is on a SULFONYLUREA or INSULIN — ring and ask them if they are having HYPOs.
A “normal” HbA1c is NOT ideal for a patient on drugs that can cause hypos like insulin and sulfonylureas. Instead, aim for an HbA1c around 53.
Check BP at every review. Target <140/80 mmHg (or <130/80 if end-organ damage present).
First-line treatment (Source: BNF / NICE NG28)
| Drug | Class | Starting Dose | Maintenance |
|---|---|---|---|
| Ramipril | ACE inhibitor (first-line) | 2.5 mg OD | 2.5–5 mg OD; max 10 mg OD |
| Lisinopril | ACE inhibitor (alternative) | 2.5–5 mg OD | 10–20 mg OD |
| Losartan | ARB (if ACE-I cough) | 50 mg OD | 50–100 mg OD |
Add calcium channel blocker (e.g., amlodipine 5–10 mg OD) or thiazide-like diuretic (e.g., indapamide 2.5 mg OD) if BP not at target with single agent. Monitor U&Es and creatinine 1–2 weeks after starting/adjusting ACE-I or ARB.
Check lipid profile annually. Offer statin to all adults with type 2 diabetes for primary prevention of cardiovascular disease. Source: NICE NG238.
Statin Therapy (Source: NICE NG238 / BNF)
- Primary prevention: Atorvastatin 20 mg OD (take at night)
- Secondary prevention (established CVD): Atorvastatin 80 mg OD
- Target: Total cholesterol <5 mmol/L, LDL <3 mmol/L (or <2 mmol/L if CVD)
- Check LFTs at baseline; recheck if symptomatic. Check CK if myalgia occurs.
Annual blood and urine tests to detect early kidney disease.
Annual Renal Screen:
- Serum creatinine & eGFR — detect declining renal function
- ACR (albumin:creatinine ratio) — early sign of nephropathy (3–30 mg/mmol = microalbuminuria; >30 mg/mmol = macroalbuminuria)
- If microalbuminuria detected: start ACE inhibitor or ARB (even if normotensive)
- Review SGLT-2 inhibitor, metformin, and all nephrotoxic drugs against eGFR
Annual Foot Check:
- 10 g monofilament sensation test
- Vibration sense (128 Hz tuning fork)
- Peripheral pulses (dorsalis pedis, posterior tibial)
- Skin inspection — ulcers, callus, deformity
- Risk stratify: low / moderate / high risk
- Refer high-risk patients to podiatry
Annual Eye Screening:
- Digital retinal photography via NHS Diabetic Eye Screening Programme
- Refer urgently to ophthalmology if proliferative retinopathy or maculopathy
- Ensure patient is registered with NHS eye screening service
Record smoking status annually. Offer smoking cessation support to all smokers with diabetes — the cardiovascular and microvascular benefit is substantial.
Smoking and Diabetes:
- Significantly increases cardiovascular risk (synergistic with diabetes)
- Accelerates nephropathy and retinopathy progression
- Increases risk of foot ulcers and amputation
- Refer to NHS Stop Smoking Service
- Offer NRT, varenicline (Champix: 0.5 mg OD → 0.5 mg BD → 1 mg BD; 12 weeks), or bupropion (Zyban: 150 mg OD for 6 days then 150 mg BD; 7–9 weeks) — see Lifestyle section for full dosing
Structured diabetes education should be offered to all people with diabetes at diagnosis and reviewed annually. Evidence shows it improves HbA1c, reduces complications, and supports self-management.
Type 2 Diabetes — DESMOND:
- Diabetes Education and Self Management for Ongoing and Newly Diagnosed
- Group-based programme, typically 6 hours over 1–2 days
- Covers: understanding diabetes, medication, diet, activity, foot care, complications, psychological aspects
- Refer at diagnosis; repeat if circumstances change
- Also consider: X-PERT Diabetes, My Diabetes My Way
Type 1 Diabetes — DAFNE:
- Dose Adjustment For Normal Eating
- 5-day structured course for adults with Type 1 diabetes on multiple daily injections
- Teaches carbohydrate counting and insulin dose adjustment
- Reduces HbA1c and hypoglycaemia; improves quality of life
- Refer via specialist diabetes team
GP Responsibilities:
- Offer and document structured education at diagnosis and annually thereafter
- Record structured education completion in the notes
- If patient declines, document and re-offer at next review
- Consider NHS Diabetes Prevention Programme for pre-diabetes (HbA1c 42–47 mmol/mol)
People with diabetes are at increased risk of serious infections and their complications. Ensure all recommended vaccinations are up to date at every annual review.
| Vaccine | Schedule | Notes |
|---|---|---|
| Influenza | Annually (autumn, ideally Oct–Nov) | All people with diabetes are eligible. Offered on NHS. Check and document at annual review. |
| Pneumococcal (PPV23 / Pneumovax) | Single dose; booster at 65 if >5 years since first dose and first dose given <65 | All adults with diabetes under 65 should receive PPV23. Those aged ≥65 receive it as part of routine schedule. |
| COVID-19 | As per national programme (annual autumn booster offered to at-risk groups including diabetes) | Diabetes is an at-risk condition for severe COVID-19. Check current NHS guidance for eligibility. |
| Shingles (Herpes Zoster) | Routine programme: aged 70–79; catch-up to age 80 | Eligible if age-appropriate under national programme. People with diabetes may be at higher risk of shingles. |
✅ Action at Every Annual Review:
- Check influenza vaccine given this season
- Check pneumococcal vaccination status — give PPV23 if not received
- Check COVID-19 booster status
- Check shingles vaccination if age-eligible
- Document all vaccinations in the clinical record
✈️ Travelling with Diabetes
Patients with diabetes can travel safely with appropriate planning. GPs play an important role in pre-travel assessment and advising on medication adjustment.
Before Travel: GP Checklist
Pre-travel advice for patients with diabetes
📋 Documentation & Supplies
- Carry diabetes ID card or a GP letter listing diagnosis, insulin, and other prescription drugs
- Carry all medication and blood glucose testing equipment in hand luggage (never in hold — risk of loss, damage, or temperature extremes)
- Plan to take twice the quantity of medical supplies normally used
- Consider availability of insulin brand abroad for long trips — formulations vary by country
🏥 Health Preparation
- Check whether vaccinations or malaria tablets are required for the destination
- Ensure up-to-date travel insurance — allow 2 weeks to arrange; declare all medical conditions; check policy covers diabetes-related emergencies
- Carry a European Health Insurance Card (EHIC) / Global Health Insurance Card (GHIC) if travelling within Europe or countries with reciprocal arrangements
- For insulin: consider an insulated travel case to keep cool during long journeys
Medication Timing Across Time Zones
Practical advice for long-haul travel
⌛ Time Zone Crossings
- Adjust medication timing if travelling across multiple time zones — seek specialist advice for insulin-dependent patients
- For eastward travel (shorter day): may need to reduce dose or skip one interval to avoid hypoglycaemia
- For westward travel (longer day): may need an additional dose
- Advise patients to monitor blood glucose more frequently during and immediately after long-haul travel
🌡️ Climate Considerations
- Hot climates: Insulin absorption may increase — risk of hypoglycaemia; keep insulin out of direct sunlight
- Cold climates: Insulin may not absorb as effectively; keep close to body
- Increased physical activity (e.g., beach holidays, skiing) will increase insulin sensitivity — monitor closely
🚗 DVLA & Driving Abroad
- Remind patients of their DVLA obligations if on insulin or sulfonylureas
- Check driving regulations of the destination country — rules vary internationally
- Carry emergency carbohydrate supplies in the car
💊 Travel Insurance: Key Points to Stress
⚠️ Do Not Cut Corners on Insurance
- Do not buy on price alone — read the small print and check the level of cover
- Declare all medical conditions honestly — failure to do so may invalidate the policy
- Allow at least 2 weeks to obtain appropriate cover
- Medical repatriation for insulin-dependent patients can be extremely expensive without adequate cover
🤰 Diabetes and Pregnancy
Diabetes in pregnancy carries significant risks to both mother and fetus. Pre-conception counselling and early specialist involvement are essential. Source: NICE NG3 (amended February 2026).
Planning a Pregnancy: Pre-conception Care
GP responsibilities before conception
✅ Refer to a Diabetes Pre-conception Clinic
All women with diabetes planning a pregnancy should be referred to a joint obstetric/diabetes pre-conception clinic.
Pre-pregnancy Planning Checklist
- Diet, exercise, and weight management — advise weight loss if BMI > 27 kg/m²
- Folic acid 5 mg daily — start from at least 3 months before conception and continue through the first trimester (to 12 weeks)
- Retinal photography — unless carried out within the last 12 months
- Renal assessment — including microalbuminuria
- Blood pressure monitoring
- Establish rubella status — arrange booster if required
- Smoking and alcohol cessation advice
- Aim for HbA1c below 48 mmol/mol before conception if safely achievable — reduces risk of miscarriage, stillbirth, and congenital malformations
- Women with HbA1c > 86 mmol/mol should be advised not to attempt pregnancy until control is improved
Medication Review in Pregnancy
What to stop, what to continue
🚫 STOP at Conception (or When Planning Pregnancy)
- Oral hypoglycaemic agents (except metformin) — discontinue
- ACE inhibitors (e.g., ramipril, lisinopril) — teratogenic, stop immediately
- Angiotensin receptor blockers (ARBs) (e.g., losartan) — stop immediately
- Statins — discontinue
✅ Safe to Continue / First Choice
- Metformin — may be used before and during pregnancy, as well as alongside or instead of insulin; antenatal clinic will oversee
- Isophane insulin (NPH insulin) — first-choice long-acting insulin during pregnancy
- Folic acid 5 mg daily — continue until end of first trimester
💉 Insulin in Pregnancy
- Insulin requirements increase significantly throughout pregnancy
- All insulin-requiring patients should be managed by the joint antenatal diabetes team
- Monitor blood glucose very frequently: before meals and 1 hour after meals
👨👩👧 Gestational Diabetes: Postnatal Follow-up
GP responsibilities after delivery — NICE NG3
📋 Post-delivery Checklist
- 6 weeks post-partum: HbA1c to establish whether glucose tolerance has returned to normal (or fasting plasma glucose)
- If HbA1c confirms Type 2 diabetes — code and manage accordingly
- If HbA1c normal — set annual HbA1c recall and code as “AT RISK OF DIABETES”
⚠️ Ongoing Counselling Required
- Inform patient of elevated long-term risk of Type 2 diabetes
- Advise on risk of gestational diabetes in future pregnancies
- Provide advice on diet, weight control, and exercise to reduce future risk
- Advise that breastfeeding reduces diabetes risk for both mother and child
🌙 Ramadan & Fasting Advice for Patients with Diabetes
Fasting during Ramadan presents particular challenges for patients with diabetes. Pre-Ramadan counselling should begin 6–8 weeks before the start of Ramadan. Source: IDF-DAR Practical Guidelines / BIMA Ramadan Compendium.
🕌 Key Context for GPs
Ramadan lasts 29 or 30 days and follows the lunar calendar (moves forward ~10 days each year). People generally eat two meals: Suhoor (before dawn) and Iftar (after sunset). No food, fluid, or oral medication is taken during daylight hours.
Fasting is an obligation for competent, healthy adult Muslims — but there are exemptions. Respect the patient’s decision to fast while ensuring they understand the risks. Start planning at least 6–8 weeks before Ramadan to avoid last-minute medication self-adjustment.
Who is Exempt from Fasting?
Islamic exemptions relevant to patients with diabetes
- Acute or chronic illness
- Travellers
- Pregnant or breastfeeding women *consensus by Islamic scholars that exemption is permissible if there is threat of harm to mother/child
- Menstruating or postpartum bleeding
- Children
- Mentally unwell / lacks capacity
✅ Permitted Interventions During Fasting
- Blood tests
- Vaccinations
- Eye drops
- Transdermal patches
- Asthma inhalers *difference of opinion exists — advise patient to consult local imam or BIMA
- Ear drops *difference of opinion exists
Risk Stratification
Should this patient fast? Use BIMA traffic light tool
Use the BIMA interactive traffic light tool to classify patients into risk categories: www.britishima.org/Ramadan-compendium (Chapter 6).
🚫 MUST NOT FAST — Very High Risk
- Severe hypoglycaemia in the last 3 months
- DKA in the last 3 months
- Recurrent hypoglycaemia or hypoglycaemia unawareness
- Poorly controlled Type 1 diabetes
- Type 2 diabetes on insulin with no experience of safe fasting
- Acute illness at the time of Ramadan
⚠️ SHOULD NOT FAST — High Risk
- Type 2 diabetes with sustained poor glycaemic control (HbA1c >75 mmol/mol for 12 months)
- Well-controlled Type 1 diabetes
- Type 2 diabetes on multiple daily injections (MDI) or mixed insulin
✅ INDIVIDUAL DECISION — Low Risk
- Well-controlled Type 2 diabetes on diet alone, metformin, or other low-hypo-risk agents
- Discuss risks/benefits; educate on self-monitoring and when to break the fast
💊 How to Adjust Medication During Ramadan
Summarised from IDF-DAR Practical Guidelines
| Medication | Usual Regimen | Advice During Ramadan |
|---|---|---|
| Metformin | Once daily | Take with evening meal (Iftar) |
| Metformin | Twice daily | Take with evening meal + dawn meal (Suhoor) |
| Metformin | Three times daily | If well controlled: take lower-than-usual dose at dawn meal; normal dose at evening meal |
| Sulfonylurea (e.g., gliclazide) | Once daily | Take with evening meal (Iftar) |
| Sulfonylurea | Twice daily | If well controlled: lower-than-usual dose at dawn meal; normal dose at evening meal |
| Pioglitazone | Any | No dose adjustment needed |
| SGLT-2 inhibitors (glflozins) | Any | Use with caution; no dose adjustment needed. Take with evening meal. Encourage increased fluid intake during non-fasting hours. Monitor for dehydration and DKA symptoms. |
| DPP-4 inhibitors (gliptins) | Any | No dose adjustment needed |
| GLP-1 receptor agonists | Any | No dose adjustment needed |
⚠️ GP Advice for All Fasting Patients
- If patients in the “high risk” or “very high risk” categories insist on fasting, advise them to consider fasting during shorter winter months instead
- Advise all fasting patients to monitor blood glucose more frequently and to be prepared to break the fast if blood glucose is <4 mmol/L or >16 mmol/L
- Document that Ramadan advice was given and the patient’s risk category
- For complex cases (insulin-dependent, multiple comorbidities), consider referral to the diabetes specialist team before Ramadan
You’ve Got This!
Diabetes is one of the most common long-term conditions you’ll manage in general practice — and now you’ve got the full picture, from that first high HbA1c to managing complications with confidence.
Whether it’s explaining why their metformin needs stopping when their eGFR dips, navigating the new SGLT-2 inhibitor guidance, or reassuring a worried patient their feet are in good hands — you’ve got the knowledge to make a real difference.
🫘 Remember: every conversation about lifestyle, every annual review you do thoroughly, every complication you catch early — that’s a life improved. Possibly several.
Now go check those HbA1cs — you’ve earned that cup of tea ☕