Synopsis
Individualise glucose and cardiovascular targets around frailty, hypoglycaemia, cognition, organ function and life expectancy, while preventing symptomatic hyperglycaemia, foot disease and unsafe treatment simplification.
- Set targets from diabetes type, frailty, comorbidity, hypoglycaemia, cognition, life expectancy and what the person can safely manage.
- For many adults with type 2 diabetes, NICE uses HbA1c 48 mmol/mol with lifestyle or non-hypoglycaemia therapy and 53 mmol/mol with hypoglycaemia-associated medicines.
- Relax HbA1c targets case by case when frailty, limited life expectancy, severe comorbidity or hypoglycaemia risk makes tight control harmful.
- A relaxed target is not neglect: prevent symptomatic hyperglycaemia, dehydration, infection and crisis while reducing severe low-glucose risk.
- First-line review examines glucose pattern, meals, weight, renal function, cognition, vision, dexterity, injections, monitoring data, carers and recent hypoglycaemia.
- Prioritise reducing insulin and sulfonylurea exposure when recurrent hypoglycaemia occurs, while preserving enough insulin to avoid ketosis where relevant.
- Continuous or flash glucose monitoring can reveal nocturnal and unrecognised lows, but alarms, scanning and data interpretation must be practically supported.
- Use sick-day guidance for vomiting, reduced intake, dehydration and infection, including ketone testing and specific medicine holds or dose actions.
- Foot examination, renal albumin assessment, retinal screening, blood pressure, lipids and smoking treatment remain important when consistent with goals.
- Simplify timing and devices, involve diabetes nursing and pharmacy, and document who tests, injects, treats lows and orders supplies.
Key red flags
Reduced consciousness, seizure or inability to swallow with low glucose requires immediate parenteral hypoglycaemia treatment.
Ketones, acidosis, vomiting, deep breathing or abdominal pain suggests DKA even in an older adult with type 2 diabetes.
Profound dehydration, marked hyperglycaemia and altered cognition suggests HHS and requires controlled specialist correction.
Hot swollen foot, spreading infection, tissue loss, rest pain or absent pulses requires urgent multidisciplinary diabetic-foot assessment.
Repeated nocturnal hypoglycaemia, falls or lost awareness requires prompt regimen and monitoring reduction before another severe event.
Vomiting, reduced intake or AKI during insulin, sulfonylurea, metformin or SGLT2 treatment requires a documented sick-day plan.
Confusion, weakness, behaviour change, focal-appearing deficit or drowsiness occurs with low capillary glucose.
Profound dehydration and altered cognition accompany marked hyperglycaemia with little or no significant ketosis.
Vomiting, abdominal pain, deep breathing and ketones require urgent DKA assessment regardless of age.
Investigation priorities
Identify fasting, meal and nocturnal risk.
Management branches
Frailty, comorbidity or hypoglycaemia makes the current diabetes target uncertain.
- Review diabetes type, complications, glucose data, renal function, cognition, function, life expectancy and personal priorities.
- Agree and document an HbA1c and glucose range that prevents symptoms and crisis while minimising low-glucose risk.
- Simplify or optimise treatment with a defined monitoring and complication-prevention plan and involve carers appropriately.