COMMENTS & FEEDBACK Check HbA1cCheck HbA1c< 42 mmol/mol< 42 mmol/mol42 - 47 mmol/mol42 - 47 mmol/molā„ 48 mmol/molā„ 48 mmol/molNormalFollow up as appropriateNormal...Non-Diabetic Ā HyperglycaemiaNon-Diabetic...ā¢Ā Code as Non-Diabetic Hyperglycaemia(C317. in EMIS or XaaeP in SystmOne)ā¢ Lifestyle adviceā¢ Refer to NDPP / Structured education / IntensiveĀ Ā Ā Ā Ā Ā Ā Ā Ā Ā Ā Ā lifestyle management where availableā¢ 6-12 monthly follow-upā¢Ā Code as Non-Diabetic Hyperglycaemia...NONOYESYESSymptoms?Symptoms?Repeat HbA1c within 2 weeksĀ Repeat HbA1c within 2 weeksĀ 42 - 47 mmol/mol42 - 47 mmol/molā„ 48 mmol/molā„ 48 mmol/molā¢ Code Diabetes type if possibleā¢ Refer if suspected Type 1 or Pregnant or MODYā¢ Refer structured educationā¢ Refer retinal screeningā¢ Arrange regular follow upā¢ Refer to Remission programme if eligibleā¢ Carry out mental health screening (PHQ4 in primary and community care OR DDS2 in secondary care) and consider referral to IAPT or other relevant part of local pathway if positiveā¢ Code Diabetes type if possible...NormalNormalHigh risk of DiabetesHigh risk of DiabetesDiabetesDiabetesHbA1cHbA1c< 42 mmol/mol< 42 mmol/mol42 - 47 mmol/mol42 - 47 mmol/molā„ 48 mmol/molā„ 48 mmol/molFasting GlucoseFasting Glucoseā¤ 5.4 mmol/Lā¤ 5.4 mmol/L5.5 - 6.9 mmol/L5.5 - 6.9 mmol/Lā„ 7.0 mmol/Lā„ 7.0 mmol/L2 hour Glucose in OGTĀ 2 hour Glucose in OGTĀ ā¤ 7.7 mmol/Lā¤ 7.7 mmol/L7.8 - 11.0 mmol/L7.8 - 11.0 mmol/Lā„ 11.1 mmol/Lā„ 11.1 mmol/LRandom GlucoseRandom Glucoseā„ 11.1 mmol/Lā„ 11.1 mmol/LSource:Ā North West London Type 2 Diabetes GuidelinesSource:Ā North West London Type 2 Diabetes GuidelinesWHEN NOT TO USE HBA1C TO DIAGNOSE DIABETESĀ WHEN NOT TO USE HBA1C TO DIAGNOSE DIABETESĀ Text is not SVG - cannot display View Classification Pathway Cardiff GuidelinesCardiff GuidelinesT1 Diabetes FeaturesT1 Diabetes Featuresā Progression to insulin within 3 yearsāĀ BMI (< 25 for sens/spec*)āĀ Age at diagnosisĀ (< 30 for sens/spec* other guidelines < 35)āĀ Weight lossāĀ Diagnosis HbA1cĀ (>115 mmol/mol) or Glucose (>20mmol/L)āĀ Lack of FH diabetesā Osmotic symptomsĀ ā DKAāĀ Other autoimmune diseaseā Progression to insulin within 3 years...T1/T2 Prediction ModelT1/T2 Prediction ModelT2 Diabetes FeaturesT2 Diabetes FeaturesāĀ BMI at diagnosis > 25āĀ Absence of weight lossāĀ Absence of KetoacidosisāĀ Less marked hyperglycaemiaāĀ Weak discriminatorsĀ - Non-white ethnicityĀ Ā āĀ BMI at diagnosis > 25...-Ā Family history of DiabetesĀ -Ā Longer duration/mild severity of Ā Ā Ā symptoms prior to presentationĀ -Ā Features of metobolic syndromeĀ -Ā No Fhx of autoimmunity-Ā Family history of Diabetes...MODY FeaturesMODY Featuresā Age < 35Ā āĀ HbA1c < 58 mmol/mol at diagnosisā Parent with Diabetesā Features of a specific monogenic causeĀ (e.g.,Ā Ā Ā Ā Ā Ā Ā renal cysts,Ā Ā Ā Ā Ā Ā Ā partial lipodystrophy,Ā Ā Ā Ā Ā Ā Ā maternally inherited deafness, andĀ Ā Ā Ā Ā Ā Ā severe insulin resistance in the absence of obesity)ā Monogenic diabetes prediction model probability >5%ā Age < 35...ABCDABCDADA 2024ADA 2024ADA 2024ADA 2024*ExeterĀ *ExeterĀ AABBCC approachAABBCC approachExeter MODY calculatorExeter MODY calculatorNHS testing criteriaNHS testing criteriaADA FlowchartADA FlowchartADA 2024ADA 2024AgeAgeAAAutoimmunityAutoimmunityAABody habitusBody habitusBBBackgroundBackgroundBBControlControlCCComorbiditiesComorbiditiesCC(e.g., personal or family history of autoimmune disease or polyglandular autoimmune syndromes)(e.g., personal or family history of autoimmune disease or p...(e.g., for individuals <35 years old, consider type 1 diabetes)(e.g., for individuals <35 years old, consider type 1 diabet...(e.g., BMI <25 kg/m2)(e.g., BMI <25 kg/m2)(e.g., family history of type 1 diabetes)(e.g., family history of type 1 diabetes)(e.g., level of glucose control on noninsulin therapies)(e.g., level of glucose control on noninsulin therapies)(e.g., treatment with immune checkpoint inhibitors for cancer can cause acute autoimmune type 1 diabetes)(e.g., treatment with immune checkpoint inhibitors for cance...C-Peptide testingC-Peptide testingPCDS: How to diagnose and manage steroid-induced diabetes and hyperglycaemiaPCDS: How to diagnose and manage steroid-induced diabetes and hyperglycaemiaPCDS:Ā Recognition and management of pancreatogenic (type 3c) diabetesPCDS:Ā Recognition and management of pancreatogenic (type 3c) diabetesText is not SVG - cannot display View MODY Pathway T1 Diabetes FeaturesT1 Diabetes FeaturesT1/T2 Prediction ModelT1/T2 Prediction ModelT2 Diabetes FeaturesT2 Diabetes FeaturesMODY FeaturesMODY FeaturesABCDABCDADA 2024ADA 2024ADA 2024ADA 2024*ExeterĀ *ExeterĀ AABBCC approachAABBCC approachExeter MODY calculatorExeter MODY calculatorNHS testing criteriaNHS testing criteriaADA FlowchartADA FlowchartADA 2024ADA 2024orDiabetes diagnosed youngDiabetes diagnosed young11Unlikely to have Type 1 DiabetesUnlikely to have Type 1 Diabetes22Have features suggestive of MODYHave features suggestive of MODY33ā¤ 35 years in White Europeansā¤ 35 years in White Europeansorā¤ 30 years in high prevalence ethnic groupsā¤ 30 years in high prevalence ethnic groupsNot on insulin treatmentNot on insulin treatmentorall autoantibodies* tested negativeĀ andĀ a random non-fasting C peptide value ā„ 200pmol/Lall autoantibodies* tested negative...An HbA1c at diagnosis < 58mmol/molAn HbA1c at diagnosis < 58mmol/molBMI < 27 and a parent with diabetesBMI < 27 and a parent with diabetesHave a MODY probability score ā„ 20%Have a MODY probability score ā„ 20% if diagnosedĀ under 18 years of ageif diagnosed...BMI < 30 and a parent with diabetes (if White)BMI < 30 and a parent with diabetes (if Whi...Ā if high prevalence type 2 diabetes ethnic groupif high prevalence type 2 diabetes ethnic...if not insulin treated, and ā„10% if insulin treated.if not insulin treated, and ā„10% if insulin...On insulin treatmentĀ withOn insulin treatmentĀ withlike South Asianslike South Asians*minimum testing of GADA and IA2A*minimum testing of GADA and IA2AGlucokinase-related fasting hyperglycaemia (R142)Glucokinase-related fasting hyperglycaemia (R142)Neonatal diabetes (R143)Neonatal diabetes (R143)Syndromic diabetes (R141)Syndromic diabetes (R141)Diabetes with severe insulin resistance (R141)Diabetes with severe insulin resistance (R141)Referral FormsReferral Formsā Progression to insulin within 3 yearsāĀ BMI (< 25 for sens/spec*)āĀ Age at diagnosisĀ (< 30 for sens/spec* other guidelines < 35)āĀ Weight lossāĀ Diagnosis HbA1cĀ (>115 mmol/mol) or Glucose (>20mmol/L)āĀ Lack of FH diabetesā Osmotic symptomsĀ ā DKAāĀ Other autoimmune diseaseā Progression to insulin within 3 years...āĀ BMI at diagnosis > 25āĀ Absence of weight lossāĀ Absence of KetoacidosisāĀ Less marked hyperglycaemiaāĀ Weak discriminatorsĀ - Non-white ethnicityĀ Ā āĀ BMI at diagnosis > 25...-Ā Family history of DiabetesĀ -Ā Longer duration/mild severity of Ā Ā Ā symptoms prior to presentationĀ -Ā Features of metobolic syndromeĀ -Ā No Fhx of autoimmunity-Ā Family history of Diabetes...ā Age < 35Ā āĀ HbA1c < 58 mmol/mol at diagnosisā Parent with Diabetesā Features of a specific monogenic causeĀ (e.g.,Ā Ā Ā Ā Ā Ā Ā renal cysts,Ā Ā Ā Ā Ā Ā Ā partial lipodystrophy,Ā Ā Ā Ā Ā Ā Ā maternally inherited deafness, andĀ Ā Ā Ā Ā Ā Ā severe insulin resistance in the absence of obesity)ā Monogenic diabetes prediction model probability >5%ā Age < 35...Cardiff GuidelinesCardiff GuidelinesC-Peptide testingC-Peptide testingNHS Guidelines For Genetic Testing In MODYNHS Guidelines For Genetic Testing In MODYPCDS: How to diagnose and manage steroid-induced diabetes and hyperglycaemiaPCDS: How to diagnose and manage steroid-induced diabetes and hyperglycaemiaPCDS:Ā Recognition and management of pancreatogenic (type 3c) diabetesPCDS:Ā Recognition and management of pancreatogenic (type 3c) diabetesText is not SVG - cannot display View AABBCC Diagram Clinical scenarioDIABETES DIAGNOSISCLASSIFICATION - T1D vs T2D vs MODYCLASSIFICATION - MODY referralACUTE HYPERGLYCAEMIA MANAGEMENTNICE (NG28) GUIDELINES TYPE 2 DIABETES MANAGEMENTNWL GUIDELINES T2D MANAGEMENT in ASCVD/HF/CKDINSULIN REGIMEN SELECTION---------------------EVERYTHING BELOW THIS NEEDS BUILDING---------------------Insulin initiationBasal insulinPre-mixed insulinBasal plus regimenBasal Bolus RegimenTargetsHypoglycaemiaDriving and DVLASick day adviceView all links View all links YESYESSymptoms of hyperglycaemia and a diagnostic blood glucose (random > 11.1mmol/L)Symptoms of hyperglycaemia and a diagnostic...NONOYESYESĀ Is the patient illĀ (vomiting, semiconscious or clinically dehydrated)?Is the patient ill...NONOYESYESDoes the urine test show moderate/heavy ketonuria?Does the urine test show moderate/heavy...NONO%3CmxGraphModel%3E%3Croot%3E%3CmxCell%20id%3D%220%22%2F%3E%3CmxCell%20id%3D%221%22%20parent%3D%220%22%2F%3E%3CmxCell%20id%3D%222%22%20value%3D%22%26lt%3Bspan%20style%3D%26quot%3Bfont-size%3A%2014px%3B%26quot%3B%26gt%3BYES%26lt%3B%2Fspan%26gt%3B%22%20style%3D%22edgeLabel%3Bhtml%3D1%3Balign%3Dcenter%3BverticalAlign%3Dmiddle%3Bresizable%3D0%3Bpoints%3D%5B%5D%3B%22%20vertex%3D%221%22%20connectable%3D%220%22%20parent%3D%221%22%3E%3CmxGeometry%20x%3D%22390%22%20y%3D%22421%22%20as%3D%22geometry%22%2F%3E%3C%2FmxCell%3E%3C%2Froot%3E%3C%2FmxGraphModel%3E%3CmxGraphModel%3E%3Croot%3E%3CmxCell%20id%3D%220%22%2F%3E%3CmxCell%20id%3D%221%22%20parent%3D%220%22%2F%3E%3CmxCell%20id%3D%222%22%20value%3D%22%26lt%3Bspan%20style%3D%26quot%3Bfont-size%3A%2014px%3B%26quot%3B%26gt%3BYES%26lt%3B%2Fspan%26gt%3B%22%20style%3D%22edgeLabel%3Bhtml%3D1%3Balign%3Dcenter%3BverticalAlign%3Dmiddle%3Bresizable%3D0%3Bpoints%3D%5B%5D%3B%22%20vertex%3D%221%22%20connectable%3D%220%22%20parent%3D%221%22%3E%3CmxGeometry%20x%3D%22390%22%20y%3D%22421%22%20as%3D%22geometry%22%2F%3E%3C%2FmxCell%3E%3C%2Froot%3E%3C%2FmxGraphModel%3EYESYESAre one or more of the following present?āĀ Severe osmotic symptoms (nocturia x 3-4)āĀ Short history (weeks)āĀ Marked weight loss (irrespective of absolute weight)āĀ A first degree relative with Type 1 DiabetesāĀ A personal history of autoimmune diseaseAre one or more of the following present?...NONOYESYESĀ Is the patient under 30 years of age?Ā Is the patient under 30 years of age?There is no immediate need for insulin.Ā Give dietary advice on healthy eating.Ā Ā Provide regular review.There is no immediate need for insulin....Arrange direct admission to hospitalArrange direct admission to hospital Ā Very likely to need insulin. Discuss with specialist team within 24 hours.Very likely to need insulin. Discuss with speci...Two or more are a strong indication for insulinTwo or more are a strong indication for insulinFirst degree relative on diet or tablets consider maturity Onset Diabetes of the Young (MODY). No immediate need for insulin but non urgent referral to the specialist team for diagnostic consideration.First degree relative on diet or tablets conside...Adapted from NWL Type 2 Diabetes GuidelinesAdapted from NWL Type 2 Diabetes GuidelinesDIABETES ā NEW DIAGNOSIS:Ā TREATMENT DECISION TREE FOR EARLY INSULIN INITIATIONDIABETES ā NEW DIAGNOSIS:Ā TREATMENT DECISION TREE FOR EARLY INSULIN INITIATIONRACGP:Ā Emergency management of hyperglycaemia in primary care RACGP:Ā Emergency management of hyperglycaemia in...Clinical assessmentClinical assessmentPerson not known to have diabetes Person not known to have diabetes Person known to have diabetes Person known to have diabetes BLOOD KETONES NOW RECOMMENDEDBLOOD KETONES NOW RECOMMENDEDPCDS: Ketones and diabetesPCDS: Ketones and diabetesJBSD-IP: Management of Hyperglycaemia and Steroid (Glucocorticoid) TherapyJBSD-IP: Management of Hyperglycaemia and...Assessment of hyperglycaemiaAssessment of hyperglycaemiaManagement of hyperglycaemia Management of hyperglycaemia PCDS: How to diagnose and manage steroid-induced diabetes and hyperglycaemiaPCDS: How to diagnose and manage steroid-induc...CKSCKST1 DiabetesT1 DiabetesCKSCKSsuspected DKAsuspected DKACKSCKSsuspected T2Dsuspected T2DCKSCKST2D ManagementT2D ManagementPCDS: A guide to sulfonylureasPCDS: A guide to sulfonylureasNICENICERescue TreatmentRescue TreatmentCKSCKSSulfonylureasSulfonylureasCKSCKSInsulin TherapyInsulin TherapyText is not SVG - cannot display Initial ManagementInitial Management!!Confirm the DiagnosisConfirm the DiagnosisConsider the ClassificationConsider the ClassificationManage symptomaticĀ HyperglycaemiaManage symptomaticĀ HyperglycaemiaAdopt an individualised approach to diabetes care and offer structured educationAdopt an individualised approach to diabetes care and offer structured educationIndividualise Glycaemic TargetsIndividualise Glycaemic TargetsAdvise Lifestyle changes for the prevention of CVDAdvise Lifestyle changes for the prevention of CVDAdvise Lifestyle changesAdvise Lifestyle changesOffer Structured EducationOffer Structured EducationNICENICEHbA1c TargetsHbA1c TargetsNICENICEEducationEducationDietary adviceDietary adviceNICENICEText is not SVG - cannot display Confirm the Diagnosis Consider the Classification Manage Symptomatic Hyperglycaemia HiddenInitial Management Full Initial Management Full NWL GUIDELINES Atherosclerotic CVD Heart Failure Chronic Kidney Disease If intolerant move down to next levelIf intolerant move down to next l...ANDANDMetformin+ SGLT2iSTOP DPP4iSTOP DPP4iNWLNWLNew Diagnosis and Early insulin initiationNew Diagnosis and Early insulin initiat...NWLNWLScreening and DiagnosisScreening and DiagnosisT1D vs T2DT1D vs T2DMODYMODYNWLNWLAlgorithmAlgorithmNWLNWLNWLNWLHbA1c targetsHbA1c targetsNWLNWLHypoglycaemic agents with insulinHypoglycaemic agents with insulinNWLNWLSequential insulin strategiesSequential insulin strategies+ DPP4i+ GLP-1 RA+ Sulfonylurea+ Basal InsulinPreferred: EmpagliflozinPreferred: EmpagliflozinPreferred: SitagliptinPreferred: SitagliptinPreferred: S/C SemaglutidePreferred: S/C SemaglutideAlternative: CanagliflozinAlternative: Canagliflo...Alternative: DulaglutideAlternative: DulaglutideNWLNWLMetforminMetforminNWLNWLSGLT2 inhibitorsSGLT2 inhibitorsNWLNWLDPP4 inhibitorsDPP4 inhibitorsNWLNWLGLP-1 Receptor AgonistsGLP-1 Receptor AgonistsNWLNWLBasal insulinBasal insulinStarting and reviewingStarting and reviewingNWLNWLSulfonylureaSulfonylureaNWLNWLSummary of anti-diabetic agentsSummary of anti-diabetic agentsNWLNWLDose adjustment in renal/hepatic impairmentDose adjustment in renal/hepatic impairmentInsulin pen devicesInsulin pen devicesNWLNWLInsulin regimensInsulin regimensNWLNWLBD mixed insulinBD mixed insulinStarting and reviewingStarting and reviewingNWLNWLIndications for insulinIndications for insul...Insulin initiationInsulin initiat...Choice of insulinChoice of insulinNWLNWLStructured EducationStructured EducationDiet & Lifestyle first line therapyDiet & Lifestyle first line the...RemissionRemissionWeight loss and lifestyle changeWeight loss and lifestyle changeSick day guidanceSick day guidanceText is not SVG - cannot display + + + + + + Manage Symptomatic Hyperglycaemia GLP-1 RA shortage guidance If intolerant move down to next levelIf intolerant move down to next l...ANDANDMetformin+ SGLT2iSTOP DPP4iSTOP DPP4iNWLNWLNew Diagnosis and Early insulin initiationNew Diagnosis and Early insulin initiat...NWLNWLScreening and DiagnosisScreening and DiagnosisT1D vs T2DT1D vs T2DMODYMODYNWLNWLAlgorithmAlgorithmNWLNWLNWLNWLHbA1c targetsHbA1c targetsNWLNWLHypoglycaemic agents with insulinHypoglycaemic agents with insulinNWLNWLSequential insulin strategiesSequential insulin strategies+ GLP-1 RA+ Sulfonylurea+ Basal InsulinPreferred: Dapagliflozin or EmpagliflozinĀ Preferred: Dapagliflozin or Empaglif...Dulaglutide or S/C SemaglutideDulaglutide or S/C SemaglutideNWLNWLMetforminMetforminNWLNWLSGLT2 inhibitorsSGLT2 inhibitorsNWLNWLGLP-1 Receptor AgonistsGLP-1 Receptor AgonistsNWLNWLBasal insulinBasal insulinStarting and reviewingStarting and reviewingNWLNWLSulfonylureaSulfonylureaNWLNWLSummary of anti-diabetic agentsSummary of anti-diabetic agentsNWLNWLDose adjustment in renal/hepatic impairmentDose adjustment in renal/hepatic impairmentInsulin pen devicesInsulin pen devicesNWLNWLInsulin regimensInsulin regimensNWLNWLBD mixed insulinBD mixed insulinStarting and reviewingStarting and reviewingNWLNWLIndications for insulinIndications for insul...Insulin initiationInsulin initiat...Choice of insulinChoice of insulinNWLNWLStructured EducationStructured EducationDiet & Lifestyle first line therapyDiet & Lifestyle first line the...RemissionRemissionWeight loss and lifestyle changeWeight loss and lifestyle changeSick day guidanceSick day guidance+ DPP4iNWLNWLDPP4 inhibitorsDPP4 inhibitors+/- SulfonylureaNWLNWLSulfonylureaSulfonylureaText is not SVG - cannot display + + + + + + + Manage Symptomatic Hyperglycaemia GLP-1 RA shortage guidance If intolerant move down to next levelIf intolerant move down to next l...ANDANDMetformin+ SGLT2iSTOP DPP4iSTOP DPP4iNWLNWLNew Diagnosis and Early insulin initiationNew Diagnosis and Early insulin initiat...NWLNWLScreening and DiagnosisScreening and DiagnosisT1D vs T2DT1D vs T2DMODYMODYNWLNWLAlgorithmAlgorithmNWLNWLNWLNWLHbA1c targetsHbA1c targetsNWLNWLHypoglycaemic agents with insulinHypoglycaemic agents with insulinNWLNWLSequential insulin strategiesSequential insulin strategies+ GLP-1 RA+ Sulfonylurea+ Basal InsulinPreferred: DapagliflozinPreferred: DapagliflozinDulaglutide or S/C SemaglutideDulaglutide or S/C SemaglutideNWLNWLMetforminMetforminNWLNWLSGLT2 inhibitorsSGLT2 inhibitorsNWLNWLGLP-1 Receptor AgonistsGLP-1 Receptor AgonistsNWLNWLBasal insulinBasal insulinStarting and reviewingStarting and reviewingNWLNWLSulfonylureaSulfonylureaNWLNWLSummary of anti-diabetic agentsSummary of anti-diabetic agentsNWLNWLDose adjustment in renal/hepatic impairmentDose adjustment in renal/hepatic impairmentInsulin pen devicesInsulin pen devicesNWLNWLInsulin regimensInsulin regimensNWLNWLBD mixed insulinBD mixed insulinStarting and reviewingStarting and reviewingNWLNWLIndications for insulinIndications for insul...Insulin initiationInsulin initiat...Choice of insulinChoice of insulinNWLNWLStructured EducationStructured EducationDiet & Lifestyle first line therapyDiet & Lifestyle first line the...RemissionRemissionWeight loss and lifestyle changeWeight loss and lifestyle changeSick day guidanceSick day guidance+ DPP4iNWLNWLDPP4 inhibitorsDPP4 inhibitors+/- PioglitazoneNWLNWLPioglitazonePioglitazoneAlternative: CanagliflozinAlternative: Canagliflo...*Guideline update due soon*Guideline update due soonText is not SVG - cannot display + + + + + + + Manage Symptomatic Hyperglycaemia GLP-1 RA shortage guidance NICE GUIDELINES NG28 Not at high CVD risk (QRISK ā¤ 10%) Chronic Heart Failure or established ASCVD High risk of CVD (QRISK > 10%) MetforminĀ SGLT2iDPP4iPioglitazoneSulfonylureaInsulinGLP-1 RAInsulinWhen dual therapy has not continued to control HbA1c to below the person's individually agreed threshold, also consider insulin-based therapy (with or without other drugs).When dual therapy has not continued to control HbA1c to below the per...Ā Or if GI disturbance Metformin MROr if GI disturbance Metformin...If Metformin not tolerated or contraindicated move down to the next stepIf Metformin not tolerated or contraindicated mo...NICENICEConsider the criteria for switching one drug* for a GLP-1 mimeticConsider the criteria for switching one drug* for a GLP-1 mimet...*STOP DPP4i*STOP DPP4iHbA1c above individualised targetHbA1c above individualised targetDPP4iPioglitazoneSulfonylureaSGLT2iHbA1c above individualised targetHbA1c above individualised targetHbA1c above individualised targetHbA1c above individualised targetNICENICEInsulin-based treatmentsInsulin-based treatmentsTarget = 53 mmol/molTarget = 53 mmol/molNICENICETarget = 48 mmol/molTarget = 48 mmol/molNICENICENICENICERescue therapyRescue therapyRescue therapy: For symptomatic hyperglycaemia, consider insulin or a sulfonylurea and review when blood glucose control has been achieved.Rescue therapy: For symptomatic hyperglycaemia, consider insulin or a...NICENICEDiet and lifestyle adviceDiet and lifestyle advi...At each point reinforce advice about diet and lifestyle.At each point reinforce advice about diet and lifes...Text is not SVG - cannot display + + + + + + + + + + + + Manage Symptomatic Hyperglycaemia GLP-1 RA shortage guidance MetforminĀ SGLT2iDPP4iPioglitazoneSulfonylureaInsulinGLP-1 RAInsulinWhen dual therapy has not continued to control HbA1c to below the person's individually agreed threshold, also consider insulin-based therapy (with or without other drugs).When dual therapy has not continued to control HbA1c to below the per...Ā Or if GI disturbance Metformin MROr if GI disturbance Metformin...If Metformin not tolerated or contraindicated move down to the next stepIf Metformin not tolerated or contraindicated mo...NICENICE1.7.101.7.10NICENICEConsider the criteria for switching one drug* for a GLP-1 mimeticConsider the criteria for switching one drug* for a GLP-1 mimet...*STOP DPP4i*STOP DPP4iHbA1c above individualised targetHbA1c above individualised targetNICENICE1.7.171.7.17DPP4iPioglitazoneSulfonylureaSGLT2iNICENICE1.7.191.7.19NICENICE1.7.211.7.21Reviewing drug treatmentsReviewing drug treatmentsReviewing drug treatmentsReviewing drug treatmentsReviewing drug treatmentsReviewing drug treatmentsHbA1c above individualised targetHbA1c above individualised targetHbA1c above individualised targetHbA1c above individualised targetNICENICEInsulin-based treatmentsInsulin-based treatmentsNICENICEFirst-line drug treatmentFirst-line drug treatmentNICENICEAdopt an individualised approachAdopt an individualised approa...to diabetes care andto diabetes care andoffer structured educationoffer structured educati...NICENICEMeasure HbA1c 3 - 6 monthlyMeasure HbA1c 3 - 6 monthlyandandagree an individual HbA1c targetagree an individual HbA1c targ...Target = 53 mmol/molTarget = 53 mmol/molNICENICETarget = 48 mmol/molTarget = 48 mmol/molNICENICENICENICERescue therapyRescue therapyRescue therapy: For symptomatic hyperglycaemia, consider insulin or a sulfonylurea and review when blood glucose control has been achieved.Rescue therapy: For symptomatic hyperglycaemia, consider insulin or a...NICENICEDiet and lifestyle adviceDiet and lifestyle advi...At each point reinforce advice about diet and lifestyle.At each point reinforce advice about diet and lifes...NICENICEChoosing drug treatmentsChoosing drug treatmentsText is not SVG - cannot display + + + + + + + + + + + + Manage Symptomatic Hyperglycaemia GLP-1 RA shortage guidance If Metformin not tolerated or contraindicated move down to the next stepIf Metformin not tolerated or contraindicated mo...Target = 48 mmol/molTarget = 48 mmol/molNICENICEĀ Start metformin alone to assess tolerability before adding an SGLT2 inhibitorStart metformin alone to assess tolerab...Metformin ++ SGLT2iInsulinGLP-1 RAInsulinWhen dual therapy has not continued to control HbA1c to below the person's individually agreed threshold, also consider insulin-based therapy (with or without other drugs).When dual therapy has not continued to control HbA1c to below the per...Ā Or if GI disturbance Metformin MROr if GI disturbance Metformin...NICENICE1.7.101.7.10NICENICEConsider the criteria for switching one drug* for a GLP-1 mimeticConsider the criteria for switching one drug* for a GLP-1 mimet...*STOP DPP4i*STOP DPP4iHbA1c above individualised targetHbA1c above individualised targetNICENICE1.7.171.7.17NICENICE1.7.191.7.19NICENICE1.7.211.7.21Reviewing drug treatmentsReviewing drug treatmentsReviewing drug treatmentsReviewing drug treatmentsReviewing drug treatmentsReviewing drug treatmentsHbA1c above individualised targetHbA1c above individualised targetHbA1c above individualised targetHbA1c above individualised targetNICENICEInsulin-based treatmentsInsulin-based treatmentsNICENICEFirst-line drug treatmentFirst-line drug treatmentNICENICEAdopt an individualised approachAdopt an individualised approa...to diabetes care andto diabetes care andoffer structured educationoffer structured educati...NICENICEMeasure HbA1c 3 - 6 monthlyMeasure HbA1c 3 - 6 monthlyandandagree an individual HbA1c targetagree an individual HbA1c targ...Target = 53 mmol/molTarget = 53 mmol/molNICENICENICENICERescue therapyRescue therapyRescue therapy: For symptomatic hyperglycaemia, consider insulin or a sulfonylurea and review when blood glucose control has been achieved.Rescue therapy: For symptomatic hyperglycaemia, consider insulin or a...NICENICEDiet and lifestyle adviceDiet and lifestyle advi...At each point reinforce advice about diet and lifestyle.At each point reinforce advice about diet and lifes...NICENICEChoosing drug treatmentsChoosing drug treatmentsDPP4iPioglitazoneSulfonylureaNICENICEHigh risk of developing CVDHigh risk of developing CVDConsider adding SGLT2i as soon as metfomin tolerability is confirmedConsider adding SGLT2i as soon as metfomin tolerability is conf...NICENICESGLT2i with CV benefitSGLT2i with CV benefit1.7.51.7.5Text is not SVG - cannot display + + + + + + + + Manage Symptomatic Hyperglycaemia GLP-1 RA shortage guidance If Metformin not tolerated or contraindicated move down to the next stepIf Metformin not tolerated or contraindicated mo...Target = 48 mmol/molTarget = 48 mmol/molNICENICEĀ Start metformin alone to assess tolerability before adding an SGLT2 inhibitorStart metformin alone to assess tolerab...Metformin ++ SGLT2iInsulinGLP-1 RAInsulinWhen dual therapy has not continued to control HbA1c to below the person's individually agreed threshold, also consider insulin-based therapy (with or without other drugs).When dual therapy has not continued to control HbA1c to below the per...Ā Or if GI disturbance Metformin MROr if GI disturbance Metformin...NICENICEConsider the criteria for switching one drug* for a GLP-1 mimeticConsider the criteria for switching one drug* for a GLP-1 mimet...*STOP DPP4i*STOP DPP4iHbA1c above individualised targetHbA1c above individualised targetHbA1c above individualised targetHbA1c above individualised targetHbA1c above individualised targetHbA1c above individualised targetNICENICEInsulin-based treatmentsInsulin-based treatmentsTarget = 53 mmol/molTarget = 53 mmol/molNICENICENICENICERescue therapyRescue therapyRescue therapy: For symptomatic hyperglycaemia, consider insulin or a sulfonylurea and review when blood glucose control has been achieved.Rescue therapy: For symptomatic hyperglycaemia, consider insulin or a...NICENICEDiet and lifestyle adviceDiet and lifestyle advi...At each point reinforce advice about diet and lifestyle.At each point reinforce advice about diet and lifes...DPP4iPioglitazoneSulfonylureaNICENICEHigh risk of developing CVDHigh risk of developing CVDConsider adding SGLT2i as soon as metfomin tolerability is confirmedConsider adding SGLT2i as soon as metfomin tolerability is conf...NICENICESGLT2i with CV benefitSGLT2i with CV benefit1.7.51.7.5Text is not SVG - cannot display + + + + + + + + Manage Symptomatic Hyperglycaemia GLP-1 RA shortage guidance If Metformin not tolerated or contraindicated move down to the next stepIf Metformin not tolerated or contraindicated mo...Target = 48 mmol/molTarget = 48 mmol/molNICENICEĀ Start metformin alone to assess tolerability before adding an SGLT2 inhibitorStart metformin alone to assess tolerab...Metformin ++ SGLT2iInsulinGLP-1 RAInsulinWhen dual therapy has not continued to control HbA1c to below the person's individually agreed threshold, also consider insulin-based therapy (with or without other drugs).When dual therapy has not continued to control HbA1c to below the per...Ā Or if GI disturbance Metformin MROr if GI disturbance Metformin...NICENICE1.7.101.7.10NICENICEConsider the criteria for switching one drug* for a GLP-1 mimeticConsider the criteria for switching one drug* for a GLP-1 mimet...*STOP DPP4i*STOP DPP4iHbA1c above individualised targetHbA1c above individualised targetNICENICE1.7.171.7.17NICENICE1.7.191.7.19NICENICE1.7.211.7.21Reviewing drug treatmentsReviewing drug treatmentsReviewing drug treatmentsReviewing drug treatmentsReviewing drug treatmentsReviewing drug treatmentsHbA1c above individualised targetHbA1c above individualised targetHbA1c above individualised targetHbA1c above individualised targetNICENICEInsulin-based treatmentsInsulin-based treatmentsNICENICEFirst-line drug treatmentFirst-line drug treatmentNICENICEAdopt an individualised approachAdopt an individualised approa...to diabetes care andto diabetes care andoffer structured educationoffer structured educati...NICENICEMeasure HbA1c 3 - 6 monthlyMeasure HbA1c 3 - 6 monthlyandandagree an individual HbA1c targetagree an individual HbA1c targ...Target = 53 mmol/molTarget = 53 mmol/molNICENICENICENICERescue therapyRescue therapyRescue therapy: For symptomatic hyperglycaemia, consider insulin or a sulfonylurea and review when blood glucose control has been achieved.Rescue therapy: For symptomatic hyperglycaemia, consider insulin or a...NICENICEDiet and lifestyle adviceDiet and lifestyle advi...At each point reinforce advice about diet and lifestyle.At each point reinforce advice about diet and lifes...NICENICEChoosing drug treatmentsChoosing drug treatmentsDPP4iPioglitazoneSulfonylureaNICENICEHeart Failure or ASCVDHeart Failure or ASCVDOFFER SGLT2i as soon as metfomin tolerability is confirmedOFFER SGLT2i as soon as metfomin tolerability is confir...NICENICESGLT2i with CV benefitSGLT2i with CV benefit1.7.51.7.5Text is not SVG - cannot display + + + + + + + + Manage Symptomatic Hyperglycaemia GLP-1 RA shortage guidance If Metformin not tolerated or contraindicated move down to the next stepIf Metformin not tolerated or contraindicated mo...Target = 48 mmol/molTarget = 48 mmol/molNICENICEĀ Start metformin alone to assess tolerability before adding an SGLT2 inhibitorStart metformin alone to assess tolerab...Metformin ++ SGLT2iInsulinGLP-1 RAInsulinWhen dual therapy has not continued to control HbA1c to below the person's individually agreed threshold, also consider insulin-based therapy (with or without other drugs).When dual therapy has not continued to control HbA1c to below the per...Ā Or if GI disturbance Metformin MROr if GI disturbance Metformin...NICENICEConsider the criteria for switching one drug* for a GLP-1 mimeticConsider the criteria for switching one drug* for a GLP-1 mimet...*STOP DPP4i*STOP DPP4iHbA1c above individualised targetHbA1c above individualised targetHbA1c above individualised targetHbA1c above individualised targetHbA1c above individualised targetHbA1c above individualised targetNICENICEInsulin-based treatmentsInsulin-based treatmentsTarget = 53 mmol/molTarget = 53 mmol/molNICENICENICENICERescue therapyRescue therapyRescue therapy: For symptomatic hyperglycaemia, consider insulin or a sulfonylurea and review when blood glucose control has been achieved.Rescue therapy: For symptomatic hyperglycaemia, consider insulin or a...NICENICEDiet and lifestyle adviceDiet and lifestyle advi...At each point reinforce advice about diet and lifestyle.At each point reinforce advice about diet and lifes...DPP4iPioglitazoneSulfonylureaNICENICEHeart Failure or ASCVDHeart Failure or ASCVDOFFER SGLT2i as soon as metfomin tolerability is confirmedOFFER SGLT2i as soon as metfomin tolerability is confir...NICENICESGLT2i with CV benefitSGLT2i with CV benefit1.7.51.7.5Text is not SVG - cannot display + + + + + + + + Manage Symptomatic Hyperglycaemia GLP-1 RA shortage guidance Consider initiating insulin in patients with:Evidence of ongoing catabolism (e.g., unexpected weight loss)Symptoms of hyperglycemiaVery high HbA1c (>86 mmol/mol) or blood glucose levels (ā„16.7 mmol/L)Consider initiating insulin in patients with:...Consider immediate insulin startConsider immediate insulin startADAADAin most individualsin most individualsHbA1c above individual targetHbA1c above individual targetOn dual/triple therapyOn dual/triple ther...GLP-1 RAGLP-1 RAor dual GIP/GLP-1 RA agentor dual GIP/GLP-1 RA agentNICENICEin certain circumstancesin certain circumstancesInsulinInsulinADAADA9.229.22Basal InsulinBasal InsulinBasal Plus Insulin regimenBasal Plus Insulin regimenPremixed InsulinPremixed InsulinTitrationTitrationIntensificationIntensificationTitrationTitrationTitrationTitrationIntensificationIntensificationIntensificationIntensificationGLP-1 RAGLP-1 RABasal Plus 2Basal Plus 2Premixed TDSPremixed TDSBasal Bolus RegimenBasal Bolus RegimenNICENICENICENICEspecialist carespecialist carespecialist carespecialist careInsulin Types & Available Medicinal Forms in the UKInsulin Types & Available Medicinal Forms in the...May 2024May 2024UK GLP-1 RA shortage guidanceĀ UK GLP-1 RA shortage guidanceĀ HOW TO use GLP-1 RA therapy safely and effectivelyHOW TO use GLP-1 RA therapy safely and effectivelyPCDSPCDSCPDCPDThe six steps to insulin safetyThe six steps to insulin safetyPCDSPCDSAt a glance factsheet: Tirzepatide for management of T2DAt a glance factsheet: Tirzepatide for management of T2DPCDSPCDSAt a glance factsheet: Impaired hypoglycaemia awarenessAt a glance factsheet: Impaired hypoglycaemia awaren...HOW TO assess fitness to driveHOW TO assess fitness to driveHOW TO minimise insulin errorsHOW TO minimise insulin errorsHOW TO support best practice injection techniqueHOW TO support best practice injection techniqueHOW TO calculate the amount of insulin to prescribe/monthHOW TO calculate the amount of insulin to prescribe/monthHOW TO prevent, identify and manage HypoglycaemiaHOW TO prevent, identify and manage HypoglycaemiaText is not SVG - cannot display Which insulin regimen should be chosen? + Consider immediate insulin start BGBGBGBG18:0018:0012:0012:0009:0009:0006:0006:0003:0003:0000:0000:0021:0021:0015:0015:0018:0018:0021:0021:0000:0000:0003:0003:0006:0006:0009:0009:00Humulin M3Humulin M3~ 30 minutes before meal~ 30 minutes before meal1122