How should I approach the diagnosis and management of type 2 diabetes in a newly diagnosed patient?

Diagnosis: Diagnose type 2 diabetes based on clinical features and confirm with appropriate blood glucose tests, including HbA1c measurement using IFCC-standardised methods. Consider differential diagnoses and revisit diagnosis if uncertain. Measure HbA1c every 3 to 6 months until stable, then every 6 months once stable on unchanged therapy.

Initial Management: Provide individualized patient education and support self-management, including referral to structured education programmes such as DESMOND to improve knowledge, self-care skills, and clinical outcomes.

Lifestyle Advice: Offer advice on diet, physical activity, and weight management tailored to the patient's needs and circumstances.

Pharmacological Treatment: Start metformin as first-line drug treatment unless contraindicated or not tolerated. If symptomatic hyperglycaemia is present, consider immediate treatment with insulin or sulfonylurea. Individualize drug treatment goals and regimens considering comorbidities, risk of hypoglycaemia, safety, tolerability, and cost.

Monitoring and Targets: Agree on an individualized HbA1c target with the patient, generally aiming for 48 mmol/mol (6.5%) if managed by lifestyle or non-hypoglycaemia drugs, or 53 mmol/mol (7.0%) if on drugs associated with hypoglycaemia. Monitor HbA1c regularly and adjust treatment accordingly.

Cardiovascular Risk Management: Manage hypertension and cardiovascular risk factors according to relevant NICE guidelines. Do not offer antiplatelet therapy unless cardiovascular disease is present.