When a patient with type 2 diabetes is not achieving glycaemic control on metformin alone, the initial steps involve reinforcing lifestyle measures, assessing adherence to treatment, and arranging timely follow-up NICE CKS,NICE CKS. Treatment targets should be individualised based on the person's preferences, risk of adverse effects, frailty, and co-morbid conditions NICE CKS,NICE CKS.
If HbA1c levels are not adequately controlled by metformin monotherapy and rise to 58 mmol/mol (7.5%) or higher, reinforce advice about diet, lifestyle, and adherence to drug treatment NICE NG28. Support the person to aim for an HbA1c level of 53 mmol/mol (7.0%) and intensify drug treatment NICE NG28. For adults whose type 2 diabetes is managed by lifestyle and diet combined with a single drug not associated with hypoglycaemia (like metformin), the aim is typically an HbA1c level of 48 mmol/mol (6.5%) NICE NG28.
When considering additional medication, assess the person's cardiovascular status and risk to determine if they have chronic heart failure, established atherosclerotic cardiovascular disease (ASCVD), or are at high risk of developing cardiovascular disease NICE CKS,NICE CKS,NICE NG28.
- If the patient has chronic heart failure or established ASCVD, offer an SGLT-2 inhibitor with proven cardiovascular benefit in addition to metformin NICE CKS,NICE CKS,NICE NG28.
- If the patient is at high risk of developing cardiovascular disease, consider an SGLT-2 inhibitor with proven cardiovascular benefit in addition to metformin NICE CKS,NICE CKS,NICE NG28.
For other adults with type 2 diabetes who do not fall into the above cardiovascular risk categories, consider adding one of the following to metformin:
- A dipeptidyl peptidase-4 (DPP-4) inhibitor NICE CKS,NICE CKS.
- Pioglitazone NICE CKS,NICE CKS.
- A sulfonylurea NICE CKS,NICE CKS.
- An SGLT-2 inhibitor, which may be considered if a sulfonylurea is contraindicated or not tolerated, or if the person is at significant risk of hypoglycaemia or its consequences NICE CKS,NICE CKS.
The choice of drug treatment should be based on the person's individual clinical circumstances (e.g., comorbidities, contraindications, weight, polypharmacy risks), preferences, effectiveness in terms of metabolic response and cardiovascular/renal protection, safety, tolerability, monitoring requirements, licensed indications, combinations, and cost NICE CKS,NICE CKS,NICE NG28.
If an adult with type 2 diabetes is symptomatically hyperglycaemic, consider immediate insulin therapy or a sulfonylurea, and review treatment once blood glucose control has been achieved NICE CKS,NICE CKS,NICE NG28. Self-monitoring of capillary blood glucose levels is not routinely offered unless the person is on insulin, has evidence of hypoglycaemic episodes, is on oral medication that may increase hypoglycaemia risk while driving, or is pregnant/planning pregnancy NICE NG28. Short-term self-monitoring may be considered when starting oral or intravenous corticosteroids or to confirm suspected hypoglycaemia NICE NG28.