Euglycaemic DKA: on an SGLT2 inhibitor, DKA can occur with near-normal glucose. If unwell with nausea, vomiting or ketones, check ketones and consider emergency admission; stop the SGLT2 during acute illness.
HbA1c targets (individualise)
- 48 mmol/mol (6.5%) on lifestyle or a drug not causing hypoglycaemia
- 53 mmol/mol (7.0%) on a drug that can cause hypoglycaemia
- Relax for frailty, limited life expectancy, or high hypoglycaemia risk
- Consider intensifying if HbA1c reaches 58 mmol/mol (7.5%)
Drug therapy
- Metformin first-line (titrate slowly; modified-release if GI upset)
- Add an SGLT2 inhibitor if chronic heart failure, established CVD, or high CV risk (QRISK over 10%)
- Then GLP-1, DPP-4, sulfonylurea or pioglitazone by profile and weight
- Insulin when other agents are insufficient
At target
- HbA1c 48 or 53 mmol/mol target
- Metformin first line
- Lifestyle and annual review
Above target
- Add SGLT2 inhibitor or other agent
- SGLT2i if CVD, heart failure or CKD
- Review in 3 to 6 months
Symptomatic / very high
- HbA1c over 75, osmotic symptoms
- Consider insulin
- Exclude type 1 or DKA
Annual review bundle
1
1. Monitor
HbA1c, U&E and eGFR, urine ACR, foot check, retinal screening, weight and BP.
HbA1c, U&E and eGFR, urine ACR, foot check, retinal screening, weight and BP.
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2
2. Cardiovascular and renal
Statin (atorvastatin 20 mg for primary prevention), BP control, smoking cessation. SGLT2 inhibitor for heart failure or CKD with albuminuria, plus an ACE inhibitor or ARB.
Statin (atorvastatin 20 mg for primary prevention), BP control, smoking cessation. SGLT2 inhibitor for heart failure or CKD with albuminuria, plus an ACE inhibitor or ARB.
↓
3
3. Hypoglycaemia
Education, driving advice and a plan for anyone on a sulfonylurea or insulin.
Education, driving advice and a plan for anyone on a sulfonylurea or insulin.
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4
4. Sick-day rules
Pause metformin if dehydrated (AKI risk), pause the SGLT2 inhibitor when acutely unwell, and check ketones.
Pause metformin if dehydrated (AKI risk), pause the SGLT2 inhibitor when acutely unwell, and check ketones.
Think about
- Weight: prefer weight-neutral or weight-lowering agents (SGLT2, GLP-1)
- Remission possible with substantial weight loss
- Review polypharmacy and adherence
Pitfalls
- Missing euglycaemic DKA on an SGLT2 inhibitor
- Continuing metformin in significant renal impairment or acute illness
- Over-tight targets causing hypoglycaemia in frail patients
- Forgetting foot and retinal surveillance
MedPrep - www.medprep.uk - Educational revision aid only. Not clinical guidance. Doses are adult examples; check the BNF, current guidelines and local policy, and seek senior advice. Nov 2026