adults with type 2 diabetes: |
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> who are unlikely to achieve longer‑term risk‑reduction benefits, for example, people with a reduced life expectancy |
> for whom tight blood glucose control poses a high risk of the consequences of hypoglycaemia, for example, people who |
are at risk of falling, people who have impaired awareness of hypoglycaemia, and people who drive or operate | |
machinery as part of their job |
> for whom intensive management would not be appropriate, for example, people with significant comorbidities. |
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If adults with type 2 diabetes achieve an HbA1c level that is lower than their target and they are not experiencing hypoglycaemia, |
encourage them to maintain it. Be aware that there are other possible reasons for a low HbA1c level, for example, | deteriorating renal function or sudden weight loss. | |
For guidance on HbA1c targets for women with type 2 diabetes who are pregnant or planning to become pregnant, see the NICE |
guideline on diabetes in pregnancy. |
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Initial Drug treatment |
Standard-release metformin is the initial drug treatment for adults with type 2 diabetes. The dose of standard‑release metformin |
should be gradually increased over several weeks to minimise the risk of gastrointestinal side effects. If an adult with type 2 |
diabetes experiences gastrointestinal side effects with standard‑release metformin then consider a trial of modified‑release |
metformin. |
In adults with type 2 diabetes, review the dose of metformin if the estimated glomerular filtration rate (eGFR) is below |
45 ml/minute/1.73m 2 : |
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> stop metformin if the eGFR is below 30 ml/minute/1.73m 2 . |
> prescribe metformin with caution for those at risk of a sudden deterioration in kidney function and those at risk of eGFR |
falling below 45 ml/minute/1.73m 2 |
> If metformin is contraindicated or not tolerated, consider initial drug treatment with: |
> a sulfonylurea or a dipeptidyl peptidase‑4 (DPP‑4) inhibitor or pioglitazone. |
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First intensification of drug treatment |
In adults with type 2 diabetes, if initial drug treatment with metformin has not continued to control HbA1c to below the person's |
individually agreed threshold for intensification, consider dual therapy with: |
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> metformin and a DPP-4 inhibitor or |
> metformin and pioglitazone [ 4 ] or |
> metformin and a sulfonylurea. |
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In adults with type 2 diabetes, if metformin is contraindicated or not tolerated and initial drug treatment has not continued to |
control HbA1c to below the person's individually agreed threshold for intensification, consider dual therapy with: |
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> a DPP-4 inhibitor and pioglitazone or |
> a DPP-4 inhibitor and a sulfonylurea or |
> pioglitazone and a sulfonylurea |
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Treatment with combinations of medicines including sodium–glucose cotransporter 2 (SGLT‑2) inhibitors may be appropriate for |
some people with type 2 diabetes; see the NICE guidance on canagliflozin in combination therapy for treating type 2 diabetes, |
dapagliflozin in combination therapy for treating type 2 diabetes and empagliflozin in combination therapy for treating diabetes. |
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Second intensification of drug treatment |
In adults with type 2 diabetes, if dual therapy with metformin and another oral drug has not continued to control HbA1c to below |
the person's individually agreed threshold for intensification, consider either: |
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> triple therapy with: |
> metformin, a DPP‑4 inhibitor and a sulfonylurea or |
> metformin, pioglitazone [ 4 ] and a sulfonylurea or |
> starting insulin-based treatment |
> glucagon‑like peptide‑1 (GLP‑1) mimetic for adults with type 2 diabetes who: |
> have a BMI of 35 kg/m 2 or higher (adjust accordingly for people from black, Asian and other minority |
ethnic groups) and specific psychological or other medical problems associated with obesity or |
> have a BMI lower than 35 kg/m 2 and: |
> for whom insulin therapy would have significant occupational implications or |
> weight loss would benefit other significant obesity‑related comorbidities. |
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Only continue GLP‑1 mimetic therapy if the person with type 2 diabetes has had a beneficial metabolic response (a reduction of at |
least 11 mmol/mol [1.0%] in HbA1c and a weight loss of at least 3% of initial body weight in 6 months). |
In adults with type 2 diabetes, if metformin is contraindicated or not tolerated, and if dual therapy with 2 oral drugs has not |
continued to control HbA1c to below the person's individually agreed threshold for intensification, consider insulin‑based |
treatment. |
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In adults with type 2 diabetes, only offer a GLP‑1 mimetic in combination with insulin with specialist care advice and ongoing |
support from a consultant‑led multidisciplinary team. |
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Treatment with combinations of medicines including SGLT‑2 inhibitors may be appropriate for some people with type 2 diabetes. |
see the NICE guidance on canagliflozin in combination therapy for treating type 2 diabetes, dapagliflozin in combination therapy |
for treating type 2 diabetes, dapagliflozin in triple therapy for treating type 2 diabetes and empagliflozin in combination therapy |
for treating type 2 diabetes. |
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