Type 2 Diabetes — New Diagnosis Algorithm

Safety

Exclude emergencies — diabetic ketoacidosis, HHS & acute complications

Done

T2DM is rarely a true emergency — but presentations can mask DKA (especially in atypical T1DM), HHS, or acute end-organ injury. Screen these first.

Kussmaul breathing / vomiting Deep sighing respirations, vomiting, abdominal pain, drowsiness — consider DKA even in "T2DM." Check ketones + BM → 999 if ketones >3 mmol/L or BM >30

Hyperglycaemic hyperosmolar state (HHS) BM >30 mmol/L, profound dehydration, clouded consciousness, no ketonaemia — osmolarity >320 → 999

New chest pain / breathlessness T2DM doubles MI risk. Troponin elevation, ST changes → 999. Atypical MI common in diabetics (silent ischaemia)

Sudden visual loss Sudden monocular loss → retinal artery/vein occlusion or vitreous haemorrhage. Same-day ophthalmology or 999

Foot with red/hot/swollen + fever Diabetic foot infection — risk of necrotising fasciitis. Same-day diabetic foot team referral. Same-day

Focal neurology / stroke symptoms FAST + face/arm/weakness/speech → 999 for thrombectomy window. Stroke risk 2–4× higher in T2DM

Severe hypoglycaemia / confusion If already on sulphonylurea or insulin — BM <3 mmol/L + confusion → 999 (prolonged SU-induced hypo can be life-threatening)

eGFR <30 or rising creatinine acutely Acute kidney injury on CKD — hold metformin immediately. Same-day nephrology if AKI stage 2–3 Same-day

DKA in T2DM: Up to 20% of DKA episodes occur in people later classified as T2DM (especially South Asian populations with ketosis-prone T2DM). Missing this is a Serious Incident.

Silent MI: Autonomic neuropathy causes painless MI — ECG at diagnosis is therefore mandatory (NICE NG28). Troponin rise without chest pain must not be missed.

Foot infection: Diabetic foot infections kill — the mortality of diabetic foot amputations at 5 years exceeds that of many cancers. Early aggressive management saves lives and limbs.

Diagnose

Confirm T2DM diagnosis — use NICE/WHO criteria; never diagnose on one result alone

Done

Diagnosis of T2DM requires two abnormal results on separate occasions (unless symptomatic with one unequivocal result). Use HbA1c as primary diagnostic tool in primary care.

HbA1c ≥48 mmol/mol

T2DM confirmed if two readings ≥48, or one reading ≥48 + classic symptoms (polydipsia, polyuria, weight loss). HbA1c

HbA1c 42–47 mmol/mol

Non-diabetic hyperglycaemia (NDH) — high risk. Annual HbA1c. Refer NHS Diabetes Prevention Programme. Do NOT diagnose T2DM on this alone.

Fasting glucose ≥7.0 mmol/L

Alternative if HbA1c unreliable (haemoglobinopathy, haemolytic anaemia, CKD, pregnancy). Confirm with second reading. Fasting glucose

Random glucose ≥11.1 mmol/L

Diagnostic only if symptomatic. If asymptomatic, repeat fasting glucose or HbA1c to confirm.

HbA1c unreliable?

Use fasting plasma glucose instead in: haemoglobin variants, haemolytic conditions, G6PD deficiency, CKD stage 4–5, recent blood transfusion, pregnancy

Rule out T1DM

Consider T1DM if: age <35, BMI normal, rapid onset, weight loss, ketonuria. Check GAD antibodies, C-peptide if uncertain. Refer to diabetology if T1DM possible.

Why two results? HbA1c has analytical variability of ±3 mmol/mol — a single borderline result could be laboratory error. NICE NG28 mandates repeat testing unless unequivocally symptomatic.

HbA1c limitations: HbA1c reflects the preceding 8–12 weeks. In haemolytic anaemia or haemoglobinopathy, red cell lifespan is shortened, falsely lowering HbA1c — leading to under-diagnosis. In iron-deficiency anaemia, HbA1c may be falsely elevated.

Missing T1DM: Classifying a patient with T1DM as T2DM and starting metformin without insulin is potentially fatal. If in doubt, refer.

Diagnose

Stage disease — HbA1c severity, CVD risk, and end-organ damage baseline

Done

Classify HbA1c severity and quantify cardiovascular risk — this directly determines how aggressively to treat and whether cardioprotective agents are warranted from day 1.

HbA1c 48–57 mmol/mol

Mild hyperglycaemia. Lifestyle intervention ± metformin. QRISK3 essential. Lifestyle first

HbA1c 58–74 mmol/mol

Moderate. Metformin indicated. Assess need for dual therapy if CVD high risk. Metformin

HbA1c 75–85 mmol/mol

Significantly elevated. Dual therapy likely needed at initiation. Consider early specialist input.

HbA1c >86 mmol/mol

Severely elevated. Consider insulin initiation discussion, urgent specialist review, or crisis HbA1c protocol. Urgent review

QRISK3 score

Calculate at diagnosis. QRISK3 ≥10% → statin (atorvastatin 20 mg). Established CVD → atorvastatin 80 mg. QRISK3

eGFR + ACR

Defines CKD stage — critical for drug selection (metformin contraindicated eGFR <30, SGLT2i caution <45). ACR >3 mg/mmol = albuminuria → consider ARB/ACE-I.

Established CVD?

Prior MI, stroke, PVD, HF → SGLT2 inhibitor (empagliflozin/dapagliflozin) or GLP-1 RA (liraglutide/semaglutide) should be considered regardless of HbA1c. SGLT2i / GLP-1 RA

CVD risk dominates prognosis: 80% of people with T2DM die from cardiovascular disease. Statin therapy in T2DM reduces major CV events by ~25% (NNT 20 over 5 years, HPS trial).

SGLT2i in established CVD: EMPA-REG OUTCOME showed empagliflozin reduced CV death by 38% and HF hospitalisation by 35% in high-risk patients. This is a bigger win than glucose control alone.

Early ACR testing: Diabetic nephropathy is silent until late. ACR detects microalbuminuria before creatinine rises — early ACE-inhibitor/ARB reduces CKD progression by 25%.

Diagnose

Targeted examination — establish baseline complications and cardiovascular status

Done

A structured examination at diagnosis establishes baseline and detects complications already present — neuropathy and retinopathy can predate formal diagnosis.

BP both arms

Target <140/90 mmHg (or <130/80 if nephropathy/CVD). >20 mmHg difference between arms → suspect subclavian stenosis / aortic disease. Bilateral BP

BMI + waist circumference

BMI ≥30 or waist >88 cm (F) / >102 cm (M) → obesity management pathway, consider GLP-1 RA (semaglutide/liraglutide). Documents baseline for monitoring.

Cardiovascular

Heart rate (AF?), heart sounds (HF murmurs?), JVP (raised = HF), ankle oedema. Peripheral pulses — absent = PVD risk for foot ulcers.

Peripheral pulses + ABI

Absent pedal pulses → arrange ABPI. ABI <0.9 = PVD. Critical for foot risk stratification (low/medium/high-risk foot pathway). Foot risk

10g monofilament test

Test plantar surface of 1st/3rd/5th metatarsal heads bilaterally. Loss of sensation → peripheral neuropathy → high-risk foot → referral to podiatry.

Eye examination

Check VA and for obvious cataract. Formal retinal screening via NHS Diabetic Eye Screening Programme (DESP) within 3 months of diagnosis.

Skin / injection sites

If already self-medicating insulin (rare at new diagnosis) — check for lipohypertrophy. Acanthosis nigricans confirms insulin resistance.

Cognitive screen

T2DM doubles dementia risk. Brief cognitive assessment if age >70 or symptoms — relevant for ability to self-manage insulin/hypo detection.

Complications at diagnosis: UKPDS showed that at the time of T2DM diagnosis, 50% of patients already had one microvascular complication. Examination is not optional — it establishes the true disease burden.

Foot risk matters immediately: Diabetic foot disease causes 60% of all lower limb amputations in the UK. A single 10g monofilament test takes 2 minutes and stratifies risk — a missed neuropathic foot is a missed amputation prevention opportunity.

Retinal screening urgency: Diabetic retinopathy is the leading cause of blindness in working-age adults in the UK. Referral to DESP within 3 months is a NICE quality standard.

Diagnose

Investigations — comprehensive baseline and annual monitoring panel

Done

Baseline bloods establish the metabolic picture and are critical for safe drug selection. Annual monitoring detects complications early and informs dose adjustments.

HbA1c

Diagnostic + baseline. Target HbA1c 48 mmol/mol (individualise — 53 mmol/mol if on sulphonylurea/insulin risk, 58 mmol/mol if frail/elderly). Repeat at 3 months post-treatment start. HbA1c

Fasting lipids

Total cholesterol, LDL, HDL, TG. LDL target: <2.0 mmol/L (established CVD <1.8 mmol/L). Statin if QRISK3 ≥10%. Fasting lipids

U&E + eGFR

Baseline renal function essential. eGFR <60 → CKD — adjust drug doses. eGFR <30 → stop metformin, caution with SGLT2i. eGFR <15 → renal referral. Annual thereafter. U&E

Urine ACR

First-void morning urine. ACR >3 mg/mmol = albuminuria. ACR >30 = macroalbuminuria. Start ACE-I or ARB if ACR >3 + hypertension or T2DM. Annual monitoring. ACR

LFTs

Baseline before statin and to screen for NAFLD/NASH (present in ~70% of T2DM). If ALT >3× ULN → investigate hepatology before statin.

FBC

Anaemia can falsify HbA1c. Macrocytosis suggests alcohol excess or B12 deficiency (if on metformin >4 years — check B12 annually). FBC

Thyroid function

TSH at diagnosis — hypothyroidism causes dyslipidaemia and worsens glucose control. Hyperthyroidism can cause hyperglycaemia.

12-lead ECG

Baseline cardiac assessment — LVH, silent MI (ST changes), QTc (relevant if adding drugs that prolong QT). NICE recommends ECG at diagnosis. ECG

Vitamin B12

Check if on metformin >4 years, or symptoms of neuropathy. Metformin reduces B12 absorption in ~30%. Supplement if B12 <200 pmol/L.

NOT routinely needed

OGTT (already diagnosed by HbA1c), insulin levels, C-peptide (unless T1 vs T2 uncertainty), urine microbiological dipstick in asymptomatic patients.

eGFR before metformin: Metformin accumulates in renal failure, risking lactic acidosis — rare but fatal. eGFR is non-negotiable before starting. This is a never event if missed.

ACR and cardiovascular risk: Microalbuminuria is an independent cardiovascular risk marker, not just a kidney marker. ACR >3 in T2DM predicts major CV events — treat it with an ACE-I/ARB regardless of BP.

NAFLD prevalence: Non-alcoholic fatty liver disease affects 70% of people with T2DM. Elevated LFTs change drug choices (avoid certain statins at high doses) and signal a patient who may benefit from SGLT2i or GLP-1 RA that improve liver histology.

Refer

Referral — know who to refer, when, and with what urgency

Done

Most new T2DM is managed in primary care — but know the referral thresholds. Delayed referral to specialist services is a common SCA fail point.

2WW / urgent CT-USS

NICE NG12: new-onset diabetes with unexplained weight loss in patients 60+ → urgent direct-access CT abdomen (or ultrasound if CT unavailable) to exclude pancreatic cancer. Also consider pancreatic/upper-GI cancer if steatorrhoea or persistent upper abdominal pain accompanies new diabetes.

Diabetology — urgent

HbA1c >86 mmol/mol unresponsive to treatment; suspected T1DM or LADA; DKA/HHS; recurrent severe hypoglycaemia; pregnancy + T2DM; insulin initiation (if not GP competency). Urgent

Diabetology — routine

Suboptimal control despite optimal primary care treatment; renal transplant; complex comorbidities (e.g., steroid-induced diabetes).

Cardiology / Rapid access chest pain

New chest pain / suspected ACS. Exertional symptoms + ECG changes. Established CVD requiring optimisation. 999 / RACPC

Nephrology

eGFR <30 (G4–G5 CKD). Rapidly declining eGFR (>5 ml/min/1.73m² per year). ACR >70 mg/mmol despite optimal RAAS blockade. Nephrology

Diabetic foot team

Active ulceration, cellulitis, gangrene, Charcot foot (hot, swollen foot without trauma). Same-day if infected. High-risk foot → multidisciplinary foot clinic. Same-day if infected

NHS Diabetic Eye Screening

All new T2DM → DESP referral within 3 months. Refer immediately if acute visual loss. Ophthalmology 2WW if sight-threatening retinopathy on screening. DESP within 3 months

NHS Diabetes Prevention Programme

HbA1c 42–47 (NDH) → refer to NDPP. Provides structured lifestyle education, proven to reduce T2DM onset by 26% (NHS DPP trial). NDPP

Structured diabetes education

All newly diagnosed T2DM → offer DESMOND programme (or local equivalent). Improves HbA1c, self-management, QoL. DESMOND

Dietitian

BMI >40, disordered eating, complex dietary needs, renal diet requirements. All should receive brief dietary advice at diagnosis — dietitian for complex needs.

Bariatric surgery

BMI ≥35 + T2DM (or ≥30 in South Asian populations) — discuss surgical referral. Bariatric surgery achieves T2DM remission in 60–80% (NICE NG28). Consider bariatric

DESMOND evidence: Structured education at diagnosis improves illness beliefs, reduces depression, and modestly improves HbA1c. More importantly, it builds the self-management skills that prevent complications over decades — a GP 10-minute appointment cannot achieve this alone.

Bariatric surgery remission rates: The DiRECT trial showed that lifestyle remission (very low calorie diet) achieves T2DM remission in 46% at 1 year. Bariatric surgery achieves 60–80% remission. This is a treatment, not an afterthought — raise it proactively in eligible patients.

Treat

Pharmacological treatment — NICE NG28 drug ladder with cardioprotective agents

Done

Start with lifestyle + metformin unless contraindicated. SGLT2 inhibitors and GLP-1 RAs are first-line in established CVD/CKD regardless of HbA1c. Always individualise targets.

Step 1 — First-Line (choose based on CVD status)

No established CVD / HF / CKD

Metformin 1st line

500 mg OD with food. Increase by 500 mg weekly to max 2g/day (or 1g BD for tolerability). Take with/after meals to reduce GI side effects. eGFR must be ≥30. Check B12 if >4 years.

Established CVD / HF / CKD (eGFR 25–60)

SGLT2 inhibitor Cardioprotective

Empagliflozin 10 mg OD or dapagliflozin 10 mg OD. Reduces HF hospitalisation by 35%, CV death by 38% (EMPA-REG). Caution: genital thrush, check eGFR >25 before starting, hold if unwell/nil by mouth.

BMI ≥35 or significant weight loss needed

GLP-1 RA Weight + CVD

Semaglutide SC 0.25 mg weekly (increase monthly to 0.5 mg, then 1 mg). Or liraglutide 0.6 mg OD (increase weekly to 1.2–1.8 mg). Reduces weight 5–15 kg, CV events in established CVD. Nausea common initially.

Step 2+ — Escalation if HbA1c above target after 3 months

Step 2 Add SGLT2i or GLP-1 RA — if not already first-line. Empagliflozin 10 mg OD OR semaglutide 0.25 mg SC weekly. Prefer SGLT2i if HF/CKD; GLP-1 RA if weight loss priority. Both reduce CV events. Dual therapy

Step 3 Add DPP-4 inhibitor — if SGLT2i/GLP-1 not tolerated or contraindicated. Sitagliptin 100 mg OD (reduce to 50 mg if eGFR 30–50, 25 mg if eGFR <30). Weight neutral. Caution: pancreatitis. Triple therapy

Step 4 Sulphonylurea — add if further glucose control needed and cost a concern. Gliclazide MR 30–120 mg OD (preferred — lower hypo risk than glibenclamide). Monitor for hypoglycaemia. Educate patient on hypo recognition. Hypo risk

Step 5 Insulin initiation — if HbA1c persistently >75 mmol/mol despite optimised triple oral therapy, or symptomatic hyperglycaemia. Isophane insulin (NPH) 10 units nocte, or basal analogue (insulin glargine 10 units nocte). Refer to diabetes nurse specialist for education. Specialist input

Additional agents — give alongside glucose-lowering drugs

Atorvastatin 20 mg OD

All T2DM with QRISK3 ≥10% or age >40. Increase to 80 mg if established CVD or LDL not at target. Check LFTs before starting. Statin

ACE inhibitor / ARB

Ramipril 2.5 mg OD (titrate to 10 mg) if: hypertensive T2DM, proteinuria (ACR >3), or established CVD. Monitor K+ and creatinine at 1–2 weeks after start/dose change. RAAS blockade

Aspirin 75 mg OD

NOT routine primary prevention (bleeding outweighs benefit). Use only in established CVD (post-MI/stroke/PVD) — secondary prevention only. Secondary prevention only

BP target

<140/90 mmHg (all T2DM). <130/80 mmHg if nephropathy, retinopathy, or established CVD. First-line antihypertensive: ACE-I (ramipril 5–10 mg OD).

Metformin — why it remains first-line: UKPDS showed 39% reduction in MI with metformin in overweight T2DM (NNT 14 over 10 years). It also reduces weight, has a very low hypoglycaemia risk, and costs <£10/month.

SGLT2i — paradigm shift: The EMPA-REG OUTCOME, CANVAS, and DECLARE trials changed T2DM management. SGLT2 inhibitors reduce HF hospitalisation independently of glucose lowering — they are heart failure drugs that also lower blood sugar, not vice versa.

GLP-1 RAs — the weight story: LEADER (liraglutide) and SUSTAIN-6 (semaglutide) showed 13–26% reduction in major CV events. The SUSTAIN trials also show 5–12 kg weight loss — making semaglutide a dual diabetes/obesity treatment (NICE NG28, TA664).

Sulphonylurea caution: Gliclazide has a lower hypoglycaemia risk than older sulphonylureas. However, hypoglycaemia in elderly patients is associated with falls, fractures, and cognitive decline — always weigh the risk and counsel patients.

Lifestyle

Non-pharmacological interventions — lifestyle IS treatment, not optional add-on

Done

The DiRECT trial achieved T2DM remission in 46% at 12 months using diet alone. Lifestyle interventions reduce HbA1c by 10–15 mmol/mol — equivalent to one oral drug.

Very low calorie diet (VLCD) 800 kcal/day for 12 weeks. DiRECT protocol. Achieves remission in 46% at 1 year, 36% at 2 years. Offer via NHS TotalDiet Replacement Programme if BMI ≥30. Supervise closely.

Weight loss target 5% weight loss → HbA1c ↓5–10 mmol/mol. 10% → significant remission chance. 15 kg+ loss → highest remission rates. Even modest loss improves BP, lipids, and hepatic steatosis.

Physical activity 150 min/week moderate intensity (brisk walking, cycling). Resistance training 2×/week. Each session reduces post-prandial glucose by ~2–3 mmol/L. Refer to social prescribing / exercise on prescription where available.

Dietary carbohydrate Reduce refined carbohydrates and sugar-sweetened drinks. Low glycaemic index diet reduces HbA1c by ~5 mmol/mol. Mediterranean diet reduces CV risk by 30% (PREDIMED). Not a "diabetic diet" — wholefood approach.

Alcohol reduction Limit to <14 units/week, spread across the week, no binge drinking. Alcohol causes hypoglycaemia (especially on sulphonylurea/insulin). Also causes hepatic steatosis, worsening NAFLD.

Smoking cessation Smoking doubles CV risk in T2DM — combined risk is multiplicative. Refer to NHS Stop Smoking service. Offer NRT + varenicline (check interactions). Smoking cessation reduces HbA1c by ~0.5%.

Sleep optimisation Sleep <6 hours → insulin resistance increases 25%. Screen for obstructive sleep apnoea (OSA) — present in 50% of T2DM with obesity. OSA treatment improves glucose control.

Structured education Offer DESMOND (Diabetes Education and Self-Management for Ongoing and Newly Diagnosed) within 3 months of diagnosis. Covers self-monitoring, sick day rules, hypo management, foot care. Improves HbA1c and QoL.

Self-monitoring blood glucose (SMBG) NOT routine for all T2DM on diet/metformin alone. Recommend if: on insulin, sulphonylurea, symptomatic hypoglycaemia, driving HGV, intercurrent illness. FreeStyle Libre considered for complex insulin regimens.

Foot care education Daily inspection, moisturise skin (not between toes), appropriate footwear. Never walk barefoot. Cut toenails straight across. Report any ulcer, blister, or skin break within 24 hours. Podiatry access.

DiRECT trial (Lean et al., Lancet 2018): Low-calorie total diet replacement (Counterweight-Plus, ~800 kcal/day) achieved T2DM remission (HbA1c <48 off medication) in 46% at 12 months. At 2 years, 36% remained in remission. This is transformative — T2DM remission was once thought impossible.

Exercise and glucose: A single 30-min walk reduces post-prandial glucose by 1–2 mmol/L for up to 24 hours via GLUT4-mediated glucose uptake independent of insulin. This is a drug-free glucose-lowering intervention.

Mediterranean diet and CVD: The PREDIMED trial showed a 30% reduction in major CV events with a Mediterranean diet. In T2DM patients with existing CVD risk, dietary intervention is as important as statin therapy.

Safety

Follow-up, monitoring & safety-netting — structure the long game

Done

T2DM is a lifelong condition. Systematic annual review prevents complications — 80% of blindness, amputations, and renal failure from T2DM are preventable with good monitoring.

1 month

Medication tolerance (GI side effects of metformin — take with food; nausea with GLP-1 RA). BP check. Reinforce lifestyle changes. Address any anxieties about diagnosis.

3 months

Repeat HbA1c to assess treatment response. If HbA1c still above target → escalate therapy (Step 7). Recheck U&E if started ACE-I/ARB (watch for hyperkalaemia and creatinine rise). HbA1c + U&E

6 months

Weight, BP, foot inspection. HbA1c if recent dose change. Review cardiovascular risk factors — is statin at target dose?

Annual review — mandatory

9 Key Care Processes (QOF): HbA1c, BMI, BP, cholesterol, urine ACR, eGFR, retinal screening, foot examination, smoking status. Document and act on each. 9 KCPs

Annual bloods

HbA1c, fasting lipids, U&E/eGFR, LFTs, FBC, urine ACR. B12 if on metformin >4 years or neuropathy. TFTs every 2–3 years or if symptoms.

Retinal screening

DESP annual digital photography. Grade 0 = normal (annual); Grade 1 = background (annual); Grade 2 = pre-proliferative (4-monthly ophthalmology); Grade 3 = proliferative (immediate). DESP annual

Foot review

Low risk → annual GP/nurse review. Medium risk (neuropathy or PVD alone) → 3–6 monthly podiatry. High risk (neuropathy + PVD, or previous ulcer) → 1–3 monthly specialist podiatry. Podiatry by risk

Driving & DVLA

Inform DVLA if on insulin or sulphonylurea (Group 1 licence: notify DVLA and insurer). Hypo awareness must be intact. Must not drive BM <5 mmol/L. Test BM before driving if on hypo-risk drugs. DVLA notification

Sick day rules

Provide sick day rules card: hold metformin, SGLT2i (DKA risk), NSAIDs, and ACE-I during acute illness + dehydration. Resume when eating and drinking normally. Sick day rules

Safety-net → 999

Symptoms of DKA (vomiting, Kussmaul breathing, BM >30, ketones >3), hypoglycaemic coma, acute foot infection with systemic sepsis, stroke/MI symptoms, sudden visual loss.

Safety-net → same-day

BM persistently >20 for 48 hours, new foot ulcer/blister, severe nausea/vomiting on GLP-1 RA, significant muscle pain on statin (possible rhabdomyolysis — check CK), rapidly worsening renal function.

9 Key Care Processes: QOF payment is linked to delivery of 9 KCPs annually. More importantly, they are the evidence base for preventing diabetic complications. Each 1% reduction in HbA1c reduces microvascular complications by 25% and MI risk by 14% (UKPDS).

Sick day rules — why critical: SGLT2 inhibitors cause euglycaemic DKA (DKA with normal blood sugar) in dehydrated or unwell patients. Holding SGLT2i and metformin during intercurrent illness prevents hospitalisation. This must be explained at every prescription.

DVLA obligations: A GP who fails to advise a patient on insulin/sulphonylurea about DVLA notification may be held professionally liable if that patient subsequently has a road traffic accident during hypoglycaemia. This is a medicolegal as well as a safety issue.

Foot monitoring frequency: In diabetic patients with high-risk feet, the risk of amputation is 100× that of the general population. A missed pressure sore → ulcer → osteomyelitis → amputation pathway takes weeks. Frequent review interrupts this.

Educational resource — not a substitute for clinical judgement.
Based on: NICE NG28 (Type 2 diabetes in adults, 2022 update), NICE NG17 (Obesity), NICE TA664 (Semaglutide), SIGN 154 (Diabetes management), BDA dietary guidance (2022), DiRECT trial (Lean et al., Lancet 2018), EMPA-REG OUTCOME (Zinman et al., NEJM 2015), LEADER trial (Marso et al., NEJM 2016), UKPDS (UKPDS Group, Lancet 1998), PREDIMED trial (Estruch et al., NEJM 2013).
Always adapt to individual patient context, comorbidities, preferences, and local guidelines. Drug doses correct at time of publication — verify via BNF before prescribing.