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Textbook/Endocrinology and metabolism/Type 2 diabetes mellitus/Rapid
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Type 2 diabetes mellitus

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2 min synopsisUK scopeSources checked 27 Aug 2026Clinical review pending
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Type 2 phenotype does not exclude insulin-deficient crisis

Marked hyperglycaemia with dehydration, confusion, vomiting, ketones, deep breathing or catabolic weight loss requires immediate DKA or HHS assessment. SGLT2 inhibitors can be associated with ketoacidosis despite a glucose value that is lower than expected, and intercurrent illness can rapidly change renal function and medicine safety.

Action: Use ABCDE, measure bedside glucose and blood ketones, obtain venous gas, electrolytes, renal function and osmolality where indicated, and follow the current JBDS-aligned local pathway. Withhold medicines inappropriate during acute dehydration or surgery according to the person's sick-day plan, but do not delay insulin when metabolic decompensation requires it.

Synopsis

Individualise type 2 diabetes care around glycaemia, cardiorenal protection, complications, treatment burden and acute safety using current UK pathways.

  • Type 2 diabetes is heterogeneous insulin resistance and beta-cell dysfunction; management should address cardiovascular, renal, metabolic and psychosocial risk rather than chase HbA1c alone.
  • At diagnosis, provide structured education, nutritional and activity support, smoking intervention and complication assessment alongside medicine discussion.
  • The current NICE NG28 pathway generally places modified-release metformin with an SGLT2 inhibitor at first line, with selection refined by established cardiovascular disease, heart failure, chronic kidney disease, frailty and contraindications.

Investigation priorities

01
HbA1c with glucose reviewFirst step

Measure chronic glycaemic exposure and support target setting when red-cell conditions make HbA1c reliable.

Management branches

FoundationStart integrated treatment

Type 2 diabetes is newly confirmed and there is no metabolic emergency.

  1. Assess symptoms, renal function, albuminuria, cardiovascular and heart-failure history, frailty, pregnancy potential, complications and the person's priorities.
  2. Offer structured education and tailored nutrition, activity and weight support, then select first-line medicines from the current NICE NG28 visual pathway and local formulary.

Key medicines

Modified-release metforminStart at the locally recommended low oral dose with food and increase gradually to the tolerated effective regimen, adapting or stopping according to renal function and acute-illness guidance.
SGLT2 inhibitorUse the licensed once-daily preparation selected by the current NICE indication, eGFR, comorbidity and local formulary, with renal review before initiation and during significant illness.
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Sources and review status5 sources · checked 27 Aug 2026 · clinical review pending
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom