
Introduction
Type 2 diabetes is a chronic metabolic condition characterized by insulin resistance and insufficient pancreatic insulin production, resulting in hyperglycemia. It is commonly associated with obesity, physical inactivity, raised blood pressure, disturbed lipid levels, and increased cardiovascular risk. This comprehensive guide, based on the National Institute for Health and Care Excellence (NICE) guidelines, provides an overview of type 2 diabetes management for healthcare professionals in primary care.
Patient Education and Lifestyle Advice
Structured Education
Healthcare professionals should offer structured education to patients and/or their family members and carers at or around the time of diagnosis, with annual reinforcement and review. It is essential to ensure that any structured education program has a structured curriculum and is delivered by trained educators. Group education programs are the preferred option for delivering this information.
Dietary Advice
Providing individualized and ongoing nutritional advice is crucial in managing type 2 diabetes. This advice should emphasize healthy, balanced eating applicable to the general population. Patients should be encouraged to consume high-fiber, low glycemic index sources of carbohydrates, low-fat dairy products, and oily fish. It is also important to advise patients to control their intake of foods containing saturated and trans fatty acids.
Healthcare professionals should integrate dietary advice with other aspects of lifestyle modification, such as increasing physical activity and losing weight. For adults with type 2 diabetes who are overweight, it is recommended to set an initial weight loss target of 5-10% of their current body weight.
Bariatric Surgery
For patients diagnosed with type 2 diabetes within the last 10 years who have a BMI of 35 or more (or lower for those of Asian family origin), healthcare professionals should consider an assessment for bariatric surgery as a potential treatment option.

Blood Glucose Management
HbA1c Monitoring
Regular monitoring of HbA1c levels is essential in managing type 2 diabetes. Healthcare professionals should measure HbA1c levels at 3-6 monthly intervals until stable, then at 6-monthly intervals. For patients managed by lifestyle and diet alone or with a single drug not associated with hypoglycemia, the aim should be an HbA1c level of 48 mmol/mol (6.5%). For patients on a drug associated with hypoglycemia, the target HbA1c level should be 53 mmol/mol (7%). It is important to consider relaxing the target HbA1c level for patients with reduced life expectancy or those at high risk of hypoglycemia consequences.
Self-monitoring of Blood Glucose
Self-monitoring of blood glucose should not be routinely offered unless the person is on insulin or another drug that can cause hypoglycemia, is pregnant or planning pregnancy, or as part of advice regarding driving. In these cases, healthcare professionals should provide appropriate guidance on how to perform and interpret self-monitoring.
Glucose-lowering Drug Treatment
The approach to glucose-lowering drug treatment should be stepwise and tailored to individual patient needs. As initial drug treatment, healthcare professionals should offer standard-release metformin. If metformin is contraindicated or not tolerated, alternatives such as a DPP-4 inhibitor, pioglitazone, or a sulfonylurea should be considered.
For first intensification of treatment, when initial drug treatment is not sufficient, healthcare professionals should consider dual therapy. This typically involves metformin in combination with a DPP-4 inhibitor, pioglitazone, or sulfonylurea. SGLT2 inhibitors may also be appropriate in combination with metformin for some patients, subject to specific guidelines.
If dual therapy is not effective, second intensification involves considering triple therapy or insulin initiation. Triple therapy options include metformin with a DPP-4 inhibitor and sulfonylurea, or metformin with pioglitazone and sulfonylurea. SGLT2 inhibitors in triple therapy have specific recommendations that should be followed.
When insulin-based treatments are necessary, healthcare professionals should use active insulin dose titration with patient education. Various insulin types and regimens should be considered based on individual patient needs and preferences.

Management of Complications
Gastroparesis
Healthcare professionals should consider gastroparesis in patients with erratic blood glucose control or unexplained gastric bloating or vomiting. It is important to explain to patients that evidence for anti-emetic therapy effectiveness is limited. When treatment is necessary, options such as domperidone, erythromycin, or metoclopramide may be considered, always following MHRA safety advice.
Painful Diabetic Neuropathy
For painful diabetic neuropathy, healthcare professionals should offer a choice of amitriptyline, duloxetine, gabapentin, or pregabalin as initial treatment. It is crucial to be aware of the potential for drug abuse with pregabalin and gabapentin and to monitor patients accordingly.
Autonomic Neuropathy
Healthcare professionals should consider sympathetic nervous system damage for patients who lose hypoglycemia warning signs. Additionally, autonomic neuropathy affecting the gut or bladder should be considered in patients with unexplained symptoms in these areas.
Diabetic Foot Problems
For the prevention and management of diabetic foot problems, healthcare professionals should refer to the specific NICE guideline dedicated to this topic, which provides comprehensive guidance on assessment, treatment, and ongoing care.
Diabetic Kidney Disease
All patients with type 2 diabetes should be offered testing for chronic kidney disease (CKD) using eGFR creatinine and ACR. The frequency of GFR monitoring should be based on the classification of CKD. Patients with CKD should be referred to specialist services based on specific criteria outlined in the guidelines. Management of CKD in diabetes patients includes appropriate blood pressure control and the use of ACE inhibitors or ARBs as recommended.
Erectile Dysfunction
Healthcare professionals should offer men with type 2 diabetes the opportunity to discuss erectile dysfunction as part of their annual review. When treatment is necessary, phosphodiesterase-5 inhibitors should be considered as initial treatment, taking into account any contraindications.
Eye Disease
Upon diagnosis of type 2 diabetes, healthcare professionals should immediately refer patients to the local eye screening service. Emergency ophthalmologist review should be arranged for sudden vision loss, rubeosis iridis, pre-retinal or vitreous hemorrhage, or retinal detachment.
Conclusion
Managing type 2 diabetes requires a comprehensive approach that addresses blood glucose control, lifestyle modifications, and the prevention and treatment of complications. By following these NICE guidelines, healthcare professionals can provide evidence-based care to improve outcomes for patients with type 2 diabetes. Regular review and adjustment of management strategies are essential to ensure optimal care for each individual patient.