Management of type 2 diabetes: A handbook for general practice

Medical management of glycaemia

Management of type 2 diabetes: A handbook for general practice
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Medical management of glycaemia

Recommendation 

Grade 

References 

Recommended as of:

Glucose-lowering medication in people newly diagnosed with type 2 diabetes

A person-centred approach should be used to guide the choice of glucose-lowering medication. Considerations include comorbidities (atherosclerotic cardiovascular disease, heart failure, chronic kidney disease), hypoglycaemia risk, impact on weight, cost, risk for side effects and individual preferences.

E

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14/11/2024

Healthy behaviour interventions should be initiated at diagnosis.

B, Level 2

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If glycaemic targets are not achieved within three months using healthy behaviour interventions alone, anti-hyperglycaemic therapy should be added to reduce the risk of microvascular complications.

A, Level 1A

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14/11/2024

Metformin should usually be selected before other agents due to:

  • low risk of hypoglycaemia and weight gain
  • long-term experience with this agent.

 

A, Level 1A
D, Consensus

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14/11/2024

Individuals with metabolic decompensation (eg marked hyperglycaemia, ketosis or unintentional weight loss) consider receiving insulin with or without metformin to correct the relative insulin deficiency.

D, Consensus

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14/11/2024

Advancing treatment

Dose adjustments to, and/or addition of, glucose-lowering medications should be made in order to attain target glycated haemoglobin (HbA1c) within 3–6 months.

D, Consensus

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14/11/2024

If glycaemic targets are not achieved, other classes of glucose-lowering agents should be added or substituted to improve glycaemic control**.
**glycaemic management

Consensus

2

 14/11/2024

In addition to lifestyle modification, most people with type 2 diabetes may eventually require pharmacotherapy to achieve long-term glycaemic control and prevent the complications of diabetes. People who are symptomatic of hyperglycaemia may need to start medication without delay, in addition to ongoing lifestyle support.

The benefits of management of hyperglycaemia for the prevention of microvascular complications have been demonstrated in randomised clinical trials.3–5

The choice, order and combination of medications used is based on:
  • individualised goals for glycaemia (refer to ‘Glucose monitoring ’)
  • evidence of improved clinical outcomes, including cardiovascular, kidney disease and other risks
  • consideration of potential adverse effects
  • individual choice and capacity.

The above should all be taken into consideration when implementing the treatment recommendations in these guidelines.

Note: Hyperglycaemia-related metabolic dysfunction (eg hyperosmolar states or ketosis) constitutes a medical emergency, and may be present at diagnosis in type 2 diabetes. Information about symptoms and emergency management of hyperglycaemia is available on The Royal Australian College of General Practitioners’ (RACGP’s) website.6

Glucose-lowering medicines

Many glucose-lowering medicines are available (Table 1). To navigate the many options, the Australian type 2 diabetes management algorithm (Figure 1) was developed by the Australian Diabetes Society in consultation with all key stakeholders, including the RACGP.

Although algorithms are designed to help navigate choice, applying the principles of patient-centred care might mean that choices suggested by the algorithm are not always appropriate because some medications have non-glycaemic effects, benefits and indications.

Also note that high-quality clinical trials of the combination therapies that are suggested in current algorithms for glucose treatment in type 2 diabetes may be lacking. Management is also increasingly informed by the outcomes of trials for sodium–glucose cotransporter 2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP-1RAs), for which long-term data are emerging with respect to both potential benefits and harms.7–9

Prescribing algorithms for type 2 diabetes suggest multiple ways of combining agents. Always consult the Pharmaceutical Benefits Scheme (PBS) when combining therapy, because restrictions and reimbursements may change.

Table 1 outlines the clinical considerations for choosing glucose-lowering medications. An evidence table summarising properties of these medications is provided with the full Australian type 2 diabetes management algorithm (Figure 1).

Table 1. Clinical considerations when choosing diabetes medications
Clinical outcome Medication effects on clinical outcomes
Metformin Sulfonylurea (SU) Dipeptidyl peptidase-4 inhibitors (DPP-4i) Acarbose Insulin
People with multiple cardiovascular risk factorsA (refer to ‘Type 2 diabetes and cardiovascular risk ’) Neutral effect3 Increased risk compared with metformin monotherapy (excluding gliclazide), but neutral when used in combination with metformin11 Neutral effect8,12–15

Refer to Note A		 Neutral effect16 Neutral effect3,4,20
People at risk of hypoglycaemia Lower rates compared with SU11 Higher clinical risks, both as monotherapy and in combination with other agents11

Gliclazide: fewer hypoglycaemia episodes versus other SUs18
Glibenclamide: higher rates of hypoglycaemia, especially in older people19		 Lower rates compared with SU11 Neutral effect Higher clinical risks as monotherapy and in combination with other agents20,21
People at risk of gastrointestinal conditions (eg IBS, IBD and gastroparesis) Known intolerance as monotherapy or combination therapy: diarrhoea11,22 Neutral effect Neutral effect Known intolerance: bloating and flatulenceC Neutral effect
People in whom stabilisation of BMI or weight loss is desired Neutral effect Neutral effect (gliclazide)
Modest weight gain for other SUs compared with metformin monotherapy11		 Neutral effect Neutral effect Modest gain11,20,21,23
People with renal impairment (eg lowered CrClD) Reduce dose by 50% with eGFR 30–60 mL/min/1.73 m2

Contraindication with CrCl <30 mL/min22		 Contraindication if CrCl <15 mL/min

Hypoglycaemia risk increases		 Safe with dose reduction but linagliptin can be used in all stages (no dose reduction)

Refer to Note B		 Contraindication in severe renal impairmentB No contraindication, but hypoglycaemia risk increases
Other class-specific information Monotherapy or combination with other agents (DPP-4i or SGLT2i) is available to reduce ‘pill burden’
Pregnancy category C but currently widely and safely used		 The Australian algorithm (Figure 1) suggests SU may be considered as monotherapy or combined with other agents but has a risk for hypoglycaemia
Pregnancy category C		 Contraindication: do not use with a GLP-1RA
Increased hospitalisation for heart failure with saxagliptin

Pregnancy category B3		 Pregnancy category B3 Dose required to be titrated to glycaemic goals while mitigating glycaemic variability and hypoglycaemia

Pregnancy category varies:
  • Glargine B3
  • Coformulated insulin B3
  • Rapid-acting insulin aspart A
  • Insulin lispro A
  • Insulin aspart/protamine A
Clinical outcome
 		 Medication effects on clinical outcomes
Thiazolidinedione (TZD) Sodium glucose co-transporter 2 inhibitors (SGLT2i) Glucagon-like peptide-1 receptor agonists
(GLP-1 RAs)		 GLP-1RA/GIP
Tirzepatide
People with multiple cardiovascular risk factorsA (refer to ‘Type 2 diabetes and cardiovascular risk ’) Contraindication if symptomatic heart disease, including heart failure24,F
Pioglitazone is the preferred TZD		 Selective benefit, heart failure benefit (empagliflozin and dapagliflozin) and decrease CVD death (empagliflozin)25 Selective benefit, depending on individual drug choice (dulaglutide, liraglutide and semaglutide)17,26,27 No conclusive evidence of positive or negative CVD outcomes published yet
People at risk of hypoglycaemia Lower rates compared with SU11 Lower rates compared with SU11 Lower rates compared with SU11 Neutral effect
People at risk of gastrointestinal conditions (eg IBS, IBD and gastroparesis) Neutral effect Neutral effect Known intolerance: nausea and vomiting, diarrhoea and constipation11 Known intolerance: nausea and vomiting, diarrhoea G
People in whom stabilisation of BMI or weight loss is desired Modest gain compared with other dual combination therapies11 Modest weight loss (in monotherapy, plus in combination with metformin versus metformin with alternative dual oral drug combinations)11,H Weight loss (in monotherapy, plus in combination with metformin versus metformin with alternative dual oral drug combinations)11,28,29 Weight loss (in monotherapy, plus in combination with metformin versus metformin with alternative dual oral drug combinations
People with renal impairment (eg lowered CrClD) Neutral effect Glycaemic-lowering efficacy decreases, with renal impairment (eGFR ≤45 mL/min)I

Selective benefits shown in people with and without diabetes and albuminuric CKD30,31		 Contraindication with lowered end-stage renal disease

However, semaglutide has shown improvement in the risk of kidney disease-related events in people with moderate to severe albuminuria27		 No dose adjustment required, including end-stage renal disease
Other class-specific information Increased atypical fractures (relative risk 1.57),32 with women more at risk than menF

Pioglitazone is contraindicated in individuals with bladder cancer or undiagnosed haematuriaF

Pregnancy category C		 Modest lowering of BP11
Increased genitourinary infections (especially females)

Refer to Note C
Less common: euglycaemic diabetic ketoacidosisJ (refer also to discussion of surgery in ‘Managing risks and other impacts of type 2 diabetes’)
Pregnancy category D		 Once-weekly formulations are available

Contraindication: combination with a DPP-4i
PBS indications may restrict combination with other agents (eg SGLT2i)
Pregnancy category D		 Do not use with DPP-4i because works on similar pathways

Prescribing indications may restrict combination with other agents (eg SGLT2i)
Pregnancy category D
Note A: Dipeptidyl peptidase-4 inhibitors (DPP-4i) and heart failure: In the SAVOR-TIMI 53 trial, hospitalisations for heart failure (a secondary outcome) increased with saxagliptin with a statistically non-significant trend to increased heart failure with alogliptin. In contrast, cardiovascular outcomes trials of sitagliptin and linagliptin failed to show any heart failure signal.7
Note B: DPP-4i: dose reduction for advancing renal dysfunction for all except linagliptin (no dose reduction) because this is hepatically metabolised.
Note C: All classes: The US Agency for Healthcare Research and Quality (AHRQ) review9 determined no moderate-to-high levels of evidence for the following adverse events (this does not mean no risk):
  • lactic acidosis (metformin)
  • urinary tract infections/fractures/volume depletion (sodium–glucose cotransporter 2 inhibitors [SGLT2i])
  • pancreatitis (DPP-4i and glucagon-like peptide-1 receptor agonist [GLP-1RA])
  • bladder cancer risks (pioglitazone).
AWe define multiple cardiovascular risk factors as men aged ≥55 years or women aged ≥60 years with type 2 diabetes who have one or more additional traditional risk factor, including hypertension, dyslipidaemia or smoking.10
BCreatinine clearance (CrCl) <25 mL/min.
CAcarbose product information is available on the Therapeutic Goods Administration (TGA) website.
DThe product information of most agents refers to CrCl as a measure of kidney function. Kidney Health Australia offers a conversion to estimated glomerular filtration rate (eGFR).
FPioglitazone product information is available on the TGA website.
GTirzepatide product information is available on the TGA website.
HWeight loss of –2.14 kg for dapagliflozin (see product information) as an add-on to metformin versus placebo at 104 weeks; –1.63 and –2.03 kg for 10 and 25 mg empagliflozin, respectively (see product information), as an add-on to metformin at 24 weeks.
ICheck renal function and individual medication product information before prescribing.
JThe Australian Diabetes Society has a safety advisory for SGLT2i use and the risk of diabetic ketoacidosis.
BMI, body mass index; BP, blood pressure; CKD, chronic kidney disease; CVD, cardiovascular disease; eGFR, estimated glomerular filtration rate; IBD, inflammatory bowel disease; IBS, irritable bowel syndrome; SU, sulfonylurea; TZD, thiazolidinedione.




Figure 1. Australian type 2 diabetes management algorithm (June 2024)33

The Australian Diabetes Society (ADS) has updated the Australian Type 2 Diabetes Glycaemic Management Algorithm diagram to reflect the recent Pharmaceutical Benefits Scheme (PBS) restriction changes to type 2 diabetes medicines (June 2024). The ADS has a dedicated website specifically on Treatment Management Plans: Type 2 Diabetes & Obesity. The website features type 2 diabetes case studies and an interactive treatment algorithm designed to assist clinicians in treatment options.

Commencing and advancing glucose-lowering therapy

Healthy eating, physical activity and education remain the foundation of all type 2 diabetes treatment programs.

If acute metabolic decompensation appears (sudden weight loss, polydipsia, polyuria, severe fatigue), assess for hyperglycaemic emergencies. If present, or uncertain, seek specialist assistance.

If lifestyle modification is not effective in meeting glycaemic targets within three months, metformin is the first choice unless contraindicated or not tolerated. Always review by the ‘review rule’ (see ‘Practice point ’) and consider excluding type 1 diabetes before advancing therapies.

Second-line agents (added to existing metformin) may be necessary and should be chosen using an individualised approach, noting that agents work in different ways and should be chosen to work synergistically.

The choice of second-line and subsequent medications should be informed by:
  • the individual’s clinical profile, in particular renal function status and high risk, or presence, of cardiovascular disease (CVD)
  • the likely efficacy of the agent with respect to the magnitude of glycaemic lowering required
  • issues that might affect safety, such as hypoglycaemia risk or agent-specific side effects
  • tolerability
  • cost
  • the individual’s preferences and abilities to engage in the proposed treatment
  • prioritisation of weight-management goals
  • emerging and evolving data on new medications and whether medication combinations are available (may assist adherence).

Figure 1 provides options based on consideration of efficacy, non-glycaemic effects (eg effects on cardiovascular and renal outcomes), side effects and cost.

Start with the correct dose of each medication and review on an individual basis at least every three to six months, keeping in mind the  individual's HbA1c target.1,32

 Practice point: What if medication is not working? The ‘review rule’

The review rule is a call to action. In addition to replacing or intensifying therapies, consideration should be given to deprescribing when appropriate. If, despite optimisation of medication or lifestyle intervention, glycaemic objectives are not being met after three months (six months at the most), review and:

  • consider alternative diagnoses if not done previously, such as type 1 diabetes (consider C-peptide and islet cell antibody testing), latent autoimmune diabetes of adults (LADA) or monogenic diabetes (refer to ‘Defining and diagnosing type 2 diabetes’)
  • check the individual’s understanding of the medication, its indication and dosing regimen (health literacy)
  • assess persistence and adherence to the therapeutic regimen, including lifestyle modification
  • is medication titration needed or do additional options need to be added
  • exclude potential confounders, such as occult infection (eg urinary), medications that might interfere with glucose management (eg steroids, some antipsychotics) or the presence of unmanaged obesity
  • assess tolerability and safety, particularly hypoglycaemia, and other factors such as planning for pregnancy or adverse effects that may affect patient engagement.

The review rule emphasises that optimisation of the current regimen, including lifestyle modification, should be implemented before advancing through additional glucose-lowering medicines to achieve HbA1c targets within three to six months.

Each class of glucose-lowering medication may have common and uncommon side effects that affect quality of life and require careful clinical reassessment. Consider individualised cardiovascular assessment for all people with diabetes and timely kidney health assessments.

Some groups (eg older people and those with multiple comorbidities) may not be represented in the published clinical outcome trials of newer diabetes agents, so caution should be exercised when considering the choice of agents for these groups.

When used as monotherapy or in combination, metformin, acarbose, glitazones, GLP-1RAs DPP-4i and SGLT2i have a low propensity for causing hypoglycaemia.

Of the sulfonylureas, hypoglycaemia is a risk in both monotherapy and in combinations, but gliclazide is less likely to cause hypoglycaemia than other sulfonylureas (eg glimepiride) or sulfonylureas with renally excreted active metabolites (eg glibenclamide).34,35

Special care needs to be taken with those at increased risk of hypoglycaemia and renal impairment, especially older people.

Weight gain can occur with the use of sulfonylureas.11 Thiazolidinedione (TZD) agents have associated unique risks (eg heart failure, fracture risks) in clinical practice (Table 1) and individualised clinical assessment is advised before using these agents. Mycotic infections or euglycaemic diabetic ketoacidosis are risks to consider with SGLT2i. GLP-1RAs are associated with nausea, vomiting and gastrointestinal upsets, and this may interfere with the absorption of other medications, including contraceptives.

Most agents carry risks with pregnancy, so assess the use of medications in this risk situation (refer to ‘Type 2 diabetes, reproductive health and pregnancy’).

People with diabetes who drive may need to notify their state motor vehicle licensing authority of their condition, because medications can affect driving performance. For more information, refer to the discussion on driving in ‘Managing risks and other impacts of type 2 diabetes ’ or refer to Section 3.3.2 of Austroads’ and National Transport Commission's Assessing fitness to drive.

The use of insulin can improve glycaemic management in most people, but any benefits need to be balanced against increased risks of hypoglycaemia and possible weight gain.23

International and Australian guidelines suggest considering a GLP-1RAs before commencing insulin, unless a person has extreme hyperglycaemic symptoms or HbA1c >11%.36 GLP-1RAs are associated with weight loss as well as sparing insulin dose. Limitations to this approach include possible side effects of GLP-1RAs (nausea) and Therapeutic Goods Administration or PBS restrictions on GLP-1RA use in combination with other therapy that do not apply to insulin.

Side effects of insulin therapy

Rare adverse events associated with the use of insulin have been reported in observational studies. Such events include congestive heart failure, oedema, lipodystrophy, allergic reactions, reversible transaminitis, reversible nephrotic syndrome and β-cell destruction.37

Common side effects include hypoglycaemia and weight gain. Risk factors for hypoglycaemia include:

  • inappropriate dose
  • timing or type of insulin (see below)
  • incorrect injection technique (eg injecting insulin intramuscularly, rather than subcutaneously, can increase absorption rates by 50%)
  • missing meals, or meals with no or insufficient carbohydrate
  • alcohol intake
  • exercise or unplanned physical activity
  • weight loss
  • treatment with agents potentiating hypoglycaemia (eg sulfonylureas)
  • decreased insulin clearance (eg renal failure)
  • changes to other medications (eg reducing or ceasing steroids).

Strategies for preventing hypoglycaemia in people include education about hypoglycaemic symptoms, structured self-monitoring of blood glucose (SMBG), discussing and individualising glycaemic goals and continued team-based support.37

Weight gain is variable on initiation of insulin and may accompany initial titration such that weight gain may eventually level off. Slower titration can lead to slower weight gain.

Strategies to address weight include:

  • referral to a credentialled diabetes educator (CDE) and/or accredited practising dietitian (APD)
  • review of other clinical conditions that may impact glycaemic management, such as possible type 1 diabetes, depression, occult malignancy, thyroid disease
  • review of medications that may contribute to weight gain
  • advice on increasing physical activity.

Early insulin intervention

Guidelines outlining the use of insulin in acute hyperglycaemic emergencies (including ketosis-inducing and hyperosmolar crises) are available.38,39 The use of insulin in these cases may be life saving, and reassessment of long-term use can occur on metabolic stabilisation. Remember to assess for type 1 diabetes ‘masquerading’ with a type 2 diabetes phenotype (older, insulin-resistant persons) in these presentations.

Insulin types

Refer to ‘Appendix 1: Types of insulin available ’.

Insulin delivery options

Various devices are available to deliver insulin, including insulin pens, syringes and pumps. Choice will depend on individual preference and the need and ability to self-manage injections. A CDE or a diabetes nurse practitioner can help provide support.

Insulin pens are the most common way of administering insulin because they make multiple daily injection schedules much easier and allow people to be more flexible in their self-management.

There is mounting evidence of selective beneficial effects of using insulin pumps and insulin patch pumps in people with type 2 diabetes (refer to ‘Use of technology in type 2 diabetes management’).

The National Diabetes Services Scheme (NDSS) provides subsidised access to insulin pump consumables for people with type 1 diabetes. For people with type 2 diabetes, some health funds cover insulin pumps, but consumables need to be self-funded.

Recommendations for delivery of insulin and non-insulin injectable medications

Using the correct delivery technique to ensure the optimal effect of insulin and GLP-1RAs is critical to achieving optimal management of diabetes and reducing the risk of some adverse effects of injectable medications.

The following recommendations for insulin delivery are based on the Forum for Injection Technique and Therapy Expert Recommendations (FITTER):40

  • Single use of pen needles and syringes is recommended (lipohypertrophy has been associated with the reuse of pen needles and syringes).
  • Shorter (size 4 mm or shortest available) needles applied to either the abdomen, thigh or buttock are adequate for most adults using insulin pen devices and will lessen the risk of intramuscular injection.
  • Lipohypertrophy and lipodystrophy may occur with repeated insulin injections into the same site, and this can affect insulin absorption. This problem is overcome by ensuring rotation of injection sites.

Full recommendations are available on the Mayo Clinic website.

Ozempic and Trulicity pens can be stored below 30°C once in use. Trulicity can be kept at this temperature for up to 14 days, whereas Ozempic can be stored for up to six weeks. The remaining stock should be refrigerated.

Refer to Box 1 for insulin delivery techniques.

More information can be found in the Australian Journal of General Practice article ‘Teaching patients with type 2 diabetes to self-administer insulin’.41

When should people start insulin?

General practitioners should anticipate and proactively address the person’s (and their own) reluctance to start insulin therapy. Early after a diagnosis of diabetes, it is important to discuss with patients that insulin may be used at some point to manage their diabetes.

With the appropriate insulin regimen, insulin therapy can be well managed in general practice, with people achieving better HbA1c management, fewer hypoglycaemic episodes and less weight gain, thus alleviating many of their concerns.42

Insulin is one of the most effective glucose-lowering agents for type 2 diabetes, and can be titrated to suit an individual’s requirements. Commencement should not be delayed if hyperglycaemia and symptoms cannot be managed adequately by a patient’s existing treatments. Recent evidence suggests that people who decline treatment with insulin when it is recommended to them can take longer to achieve HbA1c targets.43

Importantly, insulin is not the end of the road for the person with diabetes, nor does it represent therapeutic or patient failure.

Insulin should be initiated in people with type 2 diabetes who are taking maximum doses of non-insulin glucose-lowering medicines and who have suboptimal glycaemic management (HbA1c or blood glucose above individualised target), whether they are asymptomatic or symptomatic.36,44

Insulin therapy may remain an alternative for older people or people in aged care facilities, even in end-of-life care, with HbA1c >9% (75 mmol/mol), especially if management of symptomatic hyperglycaemia is difficult.

Before starting insulin

Ensure that other possible causes of hyperglycaemia have been addressed (eg lifestyle, non-adherence to non-insulin glucose-lowering medicines, other medications or medical conditions).45

Discuss with the person the benefits and costs of using insulin for optimal glycaemic management. Referral to a CDE and/or accredited practising dietitian is recommended to provide the necessary support and education to the person with diabetes in the lead-up to insulin initiation.

A general practitioner or CDE can complete the NDSS medication change registration form to allow people to access syringes or pen needles through the NDSS scheme.

The NDSS has an information booklet for people with type 2 diabetes who are starting insulin.46

Education for people with type 2 diabetes

Initial management planning and education (with both the person with type 2 diabetes and carers) should cover:

  • self-management – timing and frequency of SMBG, timing of meals, dose adjustment
  • the impact of diet, in particular carbohydrate content (both type and amount)
  • the effects of altered eating patterns, such as for religious fasts or weight loss strategies (eg intermittent fasting, 5:2 diets, very-low-calorie diets)
  • the impact of physical activity
  • hypoglycaemia management
  • insulin delivery techniques (Box 1)
  • weight management and the mitigation of weight gain with insulin therapy
  • sick-day management (refer to ‘Managing risks and other impacts of type 2 diabetes’)
  • exercise, illness and travel considerations
  • identification, roads and maritime services notifications.

This should be followed up regularly with structured education sessions.

Box 1. Insulin delivery

Fundamental information for person with type 2 diabetes about insulin delivery includes the following:

  • Insulin in use can be stored at room temperature for up to one month but the remaining stock should be kept refrigerated until the expiry date.
  • Cloudy pre-mix insulin must be resuspended prior to each use.
  • Insulin pen needles should be used only once, because reuse increases the risk of lipohypertrophy.47
  • When using a new insulin pen needle, use 1–2 units to expel air prior to dialling up the prescribed dose.
  • The abdomen is the preferred site for injecting.
  • Insulin needs to be injected only into subcutaneous tissue; injecting into muscle can not only be painful, but can also increase the absorption rate of insulin.48

People with type 2 diabetes should also be educated about:

  • how to safely dispose of used needles
  • how to rotate injection sites (people should be taught and provided with an easy-to-follow injection site rotation plan, reviewed regularly, to reduce the risk of lipohypertrophy49)
  • how to time insulin injections
  • the importance of regular inspection of injection sites.

Initiating insulin

All insulins can work effectively.42 Selecting an insulin for initiation will depend on the characteristics of the person and the disease. At the selection of the insulin preparation, consider which injecting device is most suitable for the person.

Set an individualised target (refer to ‘Glucose monitoring’), following the principle of ‘start low, go slow’ to gain confidence and reduce the risk of hypoglycaemia.50

Select one of the following insulin schedules:

  • basal insulin (eg glargine U100 or U300) once daily, regardless of meals (basal insulin alone)
  • basal insulin once daily irrespective of meals added together with a weekly GLP-1RA
  • basal insulin once daily irrespective of meals plus a single rapid-acting (prandial) insulin dose given at the largest meal of the day (basal plus one)
  • co-formulated insulin (eg degludec–aspart) or premixed (biphasic) insulin (eg lispro–lispro protamine or aspart–protamine insulin) once daily before the largest carbohydrate-containing meal of the day. Premixed insulins have various combinations of intermediate-acting basal insulins and rapid-acting insulins. Common combinations are 25/75, 30/70 and 50/50 (rapid-acting/basal insulins), by percentage.

Basal insulin alone has a slightly lower risk of hypoglycaemia, especially if the fasting glucose is consistently above target.36,51

Premixed or co-formulated insulin may be more appropriate and simpler (because a single delivery device is used) for a person where fasting and postprandial glucose are both consistently elevated.

Dosage adjustment can be more complex with premixed and co-formulated insulins, because both insulin components are adjusted simultaneously, possibly increasing the risk of hypoglycaemia and weight gain compared with basal insulin.51,52

Non-insulin glucose-lowering medicines should generally be continued, because:
  • cessation of non-insulin glucose-lowering medicines before blood glucose targets are achieved may result in significant hyperglycaemia50
  • ongoing use can mitigate weight gain (particularly SGLT2i and GLP-1RAs)36
  • ongoing use may be insulin-sparing and can reduce the risk of hypoglycaemia with insulin dose titrations as well as hyperglycaemia.50

Careful review of the use of sulfonylureas should be considered if risks for hypoglycaemia are present (commencing insulin in older people, or uptitration of insulins containing prandial/rapid-acting insulins).

A low starting dose for premixed, co-formulated of 10 units with a meal or basal insulin of 10 units or 0.1–0.2 units/kg in the evening will usually be a safe dose; however, titration is needed, because this low dose may be insufficient to achieve glycaemic targets in most people.

Detailed information about insulin doses, titration and intensification is provided in ‘Appendix 2: Guide to insulin initiation and titration ’.

The Australian Diabetes Educators Association has produced the Clinical guiding principles for subcutaneous injection technique.

The NDSS has produced a fact sheet for people with type 2 diabetes starting on insulin.

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