The Hierarchy of Treatment in T2DM


  • This section describes the tiers of treatment in diabetes
    • However, take this as a general approach.
    • In reality, treatment rarely follows the rigidity of the guidelines and is more dependent on the suitability of medications for the patient
  • This image from the BMJ summarises the management in one image
The Hierarchy Of T2DM Treatment
  • Treat conservatively with no diabetic medication if Hba1c >6.5%
    • Use only this for ≥6 weeks and then reassess
  • Monotherapy – use metformin  if still >6.5% after ≥6 weeks with conservative treatment
  • Add a 2nd line drug if still  ≥7.5% after another ≥6 months
    • The drugs are usually used in the following order:
    • DPP4 inhibitors (-gliptins)
    • SGLT2 inhibitors – especially if weight and cardiovascular control is key
    • Sulphonylurea 
      • Traditionally used as 2nd line but is often not suitable/well-tolerated in patients therefore is now less common
      • Sulphonylurea receptor binders are used if the patient has a very irregular lifestyle (very rare)
    • Pioglitazone
      • Useful if very insulin resistant or in South Asians
  • Add a 3rd line drug if >7.5% after another 9 months on dual therapy
    • Usually  add one of the options above or one of the following
    • Insulin is usually added in T2DM after ≥2 drugs have already been tried
      • Must involve a trained diabetic nurse at this point
      • Can be used with sulphonylureas but review if hypoglycaemia occurs
      • Discontinue SRBs, exenatide, gliptins, pioglitazone, or liraglutide before starting insulin
      • Do not use if obese – see below
    • GLP1 analogues (exenatide) – increase insulin release and are added here
      • Useful if patient is overweight(>35kg/m2) or otherwise unable to use insulin
  • If triple therapy is not working the patient is likely to be insulin resistant:
    • Start insulin if not already used
    • Consider pioglitazone if not already added