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type 1 with obesity. Deficiency of insulin plus National Institute for Health and Clinical Excellence (NICE):
T2D treatment algorithm1

Consider SU if:
HbA1c ≥6.5% after
lifestyle intervention
Consider substituting
Consider adding
DPP-4 or TZD for SU if:
DPP-4 or TZD if:
Consider adding sitagliptin
or TZD:
•Instead of insulin if insulin is
Consider adding exenatide
to MET and SU if
Increase insulin dose and intensify regimen.
Consider adding pioglitazone if:
• A TZD has previously had marked effect or blood glucose control is inadequate with high-dose insulin MET = metformin, SU = sulphonylureas, TZD = thiazolidinedione, DPP-4= dipeptidyl peptidase-4 inhibitor
1. Adapted from: National Institute for Health and Clinical Excellence. Clinical Guideline 87. Type 2 diabetes - newer agents (a partial update of CG66): quick reference guide.
Scottish Intercollegiate Guidelines Network (SIGN):
T2D treatment algorithm1

1st LINE OPTIONS in addition to lifestyle measures; START ONE OF
Usual approach
Sulphonylurea* (SU)
Alternative approach
Metformin (MET)
• If intolerant to metformin• If weight loss/osmotic symptoms * Continue medication if EITHER individualised target
achieved OR HbA1c falls >0.5% (5.5 mmol/mol) in 3-6
2nd LINE OPTIONS in addition to lifestyle measu
res, adherence to medication and dose optimisation; ADD ONE OF Thiazolidinedione*
DPP-4 inhibitor*
• If hypos a concern (e.g. driving, occupational hazards, at risk of • If hypos a concern (e.g. driving, occupational hazards, at risk of falls) and if no congestive heart failure 3rd LINE OPTIONS in addition to lifestyle measures, adherence to medication and dose optimisation; ADD OR SUBSTITUTE WITH ONE OF
ORAL (continue MET/SU if tolerated)
INJECTABLE (if willing to self inject; continue MET/SU if tolerated)
DPP-4 inhibitor*
Insulin* (inject before bed)
GLP-1 agonists*
• If osmotic symptoms/rising HbA1c; NPH insulin initially • If hypos a concern, use basal analogue • Add prandial insulin with time if required DPP-4= dipeptidyl peptidase-4 inhibitor; GLP-1 = glucagon-like peptide 1
Adapted from: Scottish Intercollegiate Guidelines Network. Management of diabetes: a national clinical guideline. March 2010. Prescribers should refer to the British National Formularh Medicines C updated guidance on licensed indications, full contraindications and monitoring requirements.
• Food Plan - Dietitian with knowledge of for 3 months unless glucose very highreinforced by dietitian If you add sulphonylurea or insulin the weight will go up and appetite will be - maybe but TOO Much. Portion size. Smaller plate . I can not exercise because of back/heart - exercise does not burn many calories- c - Rubbish obese have higher BMR than normal weight .v.v.rare metabolic problems associated with obesity only gland that’s wrong is ………….
lter eating habits permanently – food plan/life style ifficult – food is pleasurable + social -eating is a habit. Stop eating when full. LEAVE FOOD . Never tell obese T2D to snack between meals/ have a . Anticipate exercise and take less medication before it 500mg with main meal for two weeks then 500mg BD etc • Try Metformin SR if bowel intolerant • If not to target send to NASTY dietitian! • Check eGFR reduce dose if renal impairment esponse v variable better if not diagnosed too ay need to add in prandial regulator with • Food Plan –isocaloric – restrict fast • Consider sulphonylureas – gliclazide • Can still use metformin – for insulin • Add basal long acting insulin if fasting glucose is 97 11 17.586 10 15.575 9 13.564 8 11.553 7 9.5



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