NHS Dumfries & Galloway - RefHelp- Set individual HBA1c target
- Aim for <58 mmol/mol
- Provide encouragement and guidance to attend Diabetes Education and Weight Management
- Refer to Desmond and/or weight management via SCI-Gateway
Management for the first 12 months
Warning
If HbA1c target < 58 mmol/mol at 3 months
- Add first line agent
- Revisit Desmond/Weight management
First line agent Metformin standard release
Dose
Titrate slowly up to maximum tolerated dose (2g)
Hypoglycaemia risk
Low
Weight
Reduction
Main adverse events
Gastrointestinal (Consider MR and/or reduced dose)
In CKD Stage 3a
eGFR < 45 max 1g daily; eGFR < 30 STOP
CV benefit
Yes
If HbA1c target < 58 mmol/mol not achieved after 6 months
- Review adherence and revisit Desmond/Weight management
- Add one of the following medications guided by patient profile
SGLT2 Inhibitor
Canagliflozin, or Empagliflozin
Dose
Start low dose and increase after 4 weeks if tolerated
Hypoglycaemia risk
Low
Weight
Loss
Main adverse events
Genital thrush; DKA (Education required
In CKD Stage 3A
Empagloflozin - DO NOT INITIATE
Canagliflozin - Initiate if eGFR > 30 ml/min
CV benefit
Yes
DPP-4 Inhibitor
Alogliptin, Sitagliptin or Linagliptin
Dose
Alogliptin 25mg OD
Sitagliptin 100mg OD
Linagliptin 5mg OD
Hypoglycaemia risk
Low
Weight
Neutral
Main adverse events
Pancreatitis
In CKD Stage 3A
Alogliptin - reduce dose
Sitagliptin - reduce dose
Linagliptin - no change
CV benefit
No
Sulphonylurea
Gliclazide
Dose
Titrate up to maximum 160mg BD
Hypoglycaemia risk
High
Weight
Gain
Main adverse events
Hypoglycaemia
Education re driving rules essential
In CKD Stage 3A
Careful monitoring - increased risk of hypos
CV benefit
No
Thiazolidinedione
Pioglitazone
Dose
15-30mg daily, increase to 45mg if needed
Hypoglycaemia risk
High
Weight
Gain
Main adverse events
Oedema, fractures, risk of bladder cancer
In CKD Stage 3A
Dose unchanged
CV benefit
Probable (but fluid retention)
If HbA1c target < 58 mmol/mol not achieved after 9 months
- Add an additional oral agent(s) from a different class above
- Continue mediation at each stage if either individualised target achieved or if HbA1c falls more than 5.5 mmol/mol in 3 months
- Discontinue medication if ineffective or not tolerated
- If BMI > 30kg/m2 add oral GLP-1 Agonist
- Refer to secondary care for assessment if BMI < 30kg/m2
Oral GLP-1 Agonist
Semagultide
6 month trial if BMI > 30kg/m2
Dose
3mg OD for 4 weeks
7mg OD for 4 weeks
Increase to 14mg OD if required
Hypoglycaemia risk
Low
Weight
Loss
Main adverse events
Gastrointestinal but improves after a few weeks
In CKD Stage 3A
Dose unchanged
Notes
- Stop DPP-4 inhibitor
- Consider reducing Sulphonylurea
- Continue Metformin
- Can continue Pioglitazone
- Can continue SGLT2 inhibitor
If HbA1c target < 58 mmol/mol
- Refer to secondary care for further assessment either injectable GLP-1 or insulin
- Revisit Desmond/Weight management