Diabetes-Prescribing Guidance

Key Points:

Lifestyle is first-line therapy and important throughout care. Consider that diabetes remission is possible for some patients and refer patients to Weight Management Service.
Newly diagnosed patients with Type 2 diabetes should also be referred for structured education (such as DESMOND) via the weight management service.
The NHS Lothian Diabetes Managed Clinical Network has a Prescribing Information page and this Ref Help page contains links to guidance on prescribing anti-diabetic medication, anti-hypertensives and statins.
Below is a link to an algorithm that is intended for individuals with above-target glycaemic control where escalation of therapy is indicated. It is not necessary to modify therapy in individuals who are on regimens that include agents such as Gliclazide, Gliptins or Pioglitazone if glycaemic control is already at target, with no significant side effects.

– Prescribing Flow Chart/Algorithm

– Supplementary information (FAQs) for the Algorithm

Diabetic Targets: Realistic Medicine, frailty, and personalised targets:

Although SIGN 2017 sets a target of 53mmol/mol for glycaemic control, targets should be individualised. NICE 2022 also recommends personalised targets and for some patients (where treatment is either lifestyle alone or on a single drug that does not cause hypoglycaemia (insulin and sulphonylureas) then a target of 48mmol may be appropriate.
Patient preference is important – some may be keen to take additional medication or may be reluctant because of the burden of polypharmacy and risks of intensive control.
Therapeutic targets should be modified in frail individuals. The table below is a summary of therapeutic targets from a UK expert consensus statement from the Foundation for Diabetes Research in Older People:

Health Status	Target HbA1c	Target BP	Lipid modification
	mmol/mol
Healthy Rationale: reasonable life expectancy	<58	140/90	Statins indicated
Intermediate Health Several co-morbidities Limited functional ability Mild to moderate cognitive impairment Rationale: intermediate life expectancy, high treatment burden (polypharmacy), vulnerable to hypoglycemia and falls	<64	140/90	Statins indicated
Poor health End-stage chronic In long-term care/ limited functional ability Moderate to severe cognitive impairment Rationale: limited life expectancy: benefits of treatment uncertain	<69	150/90	Benefits less certain: greater benefit in secondary prevention