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Management Algorithm For Type 2 Diabetes


Confirm the diagnosis and type of diabetes
Determine individualised glycaemic target

Education, support, healthy eating + exercise
Essential at all times throughout duration of diabetes

Start unless contraindicated
Increase to maximal tolerated dose or 2 g per day

The target HbA1c for most patients with type 2 diabetes is < 53 mmol/mol

IF HIGH RISK of renal or CV disease

Diabetic renal disease* OR heart failure OR known cardiovascular disease OR 5 year CVD risk > 15%

*Renal disease = urinary albumin:creatinine ratio > 3 mg/mmol and/or reduced eGFR
Heart failure or renal disease predominates
Preferably SGLT2i† regardless of HbA1c
(HbA1c needs to be > 53 mmol/mol for funding)
GLP1RA† or SGLT2i† regardless of HbA1c
(HbA1c needs to be > 53 mmol/mol for funding)
If unable to tolerate or HbA1c remains above target
GLP1RA† preferred next therapy after SGLT2i†
SGLT2i† preferred next therapy after GLP1RA†
(dual SGLT2i/GLP1RA therapy is not currently funded)

Alternative agents include:
DPPIVi if not on GLP1RA
Thiazolidinediones (TZD) if no heart failure
Sulfonylureas (SU)
If target HbA1c reached
Repeat HbA1c in 3 months
If HbA1c above target
Repeat HbA1c 6 monthly and annual review of CVD + renal risk
If HbA1c above target
  Preferred 2nd line agents 3rd line agents
Risk of hypoglycaemia Rare Rare Rare Rare Yes Yes
Mean ↓ in HbA1c (mmol/mol) 5 - 25 15 5 - 10 15 15 Any
Independent cardiorenal benefits Yes Yes No No No No
Effect on weight
Funded SA only* SA only† Yes Yes Yes Yes
Escalate therapy + repeat HbA1c every 3 months until target reached
  • May require multiple agents including insulin therapy
  • Ensure adherence to lifestyle management + medications
  • Re-refer for dietitian input if appropriate
  • Repeat HbA1c 6 monthly once target reached
  • Assess CVD and renal risk at least annually
  • Continue standard care to reduce CVD risk e.g. statins, antihypertensives (esp. ACEi in diabetic renal disease) etc.
† SA criteria for SGLT2i and GLP1RA
(all required and same for both classes)
  • Patient has type 2 diabetes with an HbA1c > 53 mmol/mol despite > 3 months of regular use of at least one glucose lowering therapy (includes metformin)
  • The patient is of Māori and/or any Pacific ethnicity OR has known diabetic renal disease OR known CVD OR 5 year CVD risk > 15% OR a high lifetime CVD risk due to onset of diabetes during childhood or as a young adult
  • The patient is not on funded SGLT2i and GLP1RA therapy at the same time