Australian Blood Glucose Treatment Algorithm for type 2 diabetes

Lifestyle measures

diet, exercise and weight control should be the initial approach and reinforced at each stage.

All patients should receive education regarding lifestyle measures: healthy diet, physical activity and weight control.

If not at target, or if a Hb1Ac reduction of ≥ 0.5% is not achieved after 3 months

move down the algorithm.

Press or click the lines to reveal the plan.

1st line

Metformin is the usual 1st line therapy unless contraindicated or not tolerated.

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If Hb1Ac target not achieved in 3 months

  • Check and review current therapies, stop any that fail to improve glycaemic control
  • Check patient understanding and self management
  • Review adherence with therapies
  • Exclude other comorbidities/therapies impacting on glycaemic control
  • Reinforce lifestyle measures
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    Metformin
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    SU
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    Insulin
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    Acarbose
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    DPP-4 inhibitor
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    SGLT2 inhibitor
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    TZD
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2nd line

If Metformin was not used in the first line, add it now if not contraindicated.

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Choice of second line agent should be guided by clinical considerations (presence of, or high risk of cardiovascular disease, heart failure, chronic kidney disease, hypoglycaemia), side effect profile, contraindications and cost.

 

If Hb1Ac target not achieved in 3 months

  • Check and review current therapies, stop any that fail to improve glycaemic control
  • Check patient understanding and self management
  • Review adherence with therapies
  • Exclude other comorbidities/therapies impacting on glycaemic control
  • Reinforce lifestyle measures
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    SGLT2 inhibitor
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    DPP-4 inhibitor
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    SU
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    GLP-1RA
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    Insulin
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    Acarbose
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    TZD
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3rd Line

Consider triple oral therapy or GLP-1RA or insulin.

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Choice of third line agent should be guided by clinical consideration as above. Note: combinations not approved by PBS include GLP-1RA with SGLT2i or GLP-1RA with insulin (exenatide is the only GLP-1RA approved on the PBS for use with insulin). Consider stopping any second-line medication that has not reduced HbA1c by > 0.5% after 3 months unless indicated for non-glycaemic benefits.

 

If Hb1Ac target not achieved in 3 months

  • Check and review current therapies, stop any that fail to improve glycaemic control
  • Check patient understanding and self management
  • Review adherence with therapies
  • Exclude other comorbidities/therapies impacting on glycaemic control
  • Reinforce lifestyle measures
  • (CLICK FOR MORE)
    SGLT2 inhibitor
  • (CLICK FOR MORE)
    DPP-4 inhibitor
  • (CLICK FOR MORE)
    SU
  • (CLICK FOR MORE)
    GLP-1RA
  • (CLICK FOR MORE)
    Insulin
  • (CLICK FOR MORE)
    Acarbose
  • (CLICK FOR MORE)
    TZD
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4th Line

Next Steps

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  • If on Metformin+SU+DPP-4i, consider adding SGLT2i, or switching to a GLP-1RA, or a SGLT2i
  • If on Metformin+DPP-4i+SGLT2i, consider adding SU or adding insulin
  • If on GLP-1RA, consider adding basal or premixed/coformulated insulin (Exenatide is the only GLP-1RA approved on the PBS for use with insulin)
  • If on basal insulin, consider adding SGLT2i or GLP-1RA or bolus insulin with meals, or change ro premixed/coformuated insulin (Exenatide is the only GLP-1RA approved on the PBS for use with insulin)
  • Consider stopping third-line medication that has not reduced HbA1c by >0.5% after 3 months unless indicated for non-glycaemic benefits

With increasing clinical complexity consider specialist endocrinology consultation

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