Chronic hyperglycaemia from insulin resistance ± relative insulin deficiency; FPG ≥126, 2-h PPG ≥200, or HbA1c ≥6.5%.
History taking
- • Polyuria, polydipsia, polyphagia, weight loss, fatigue, blurred vision
- • Duration, family history, prior gestational diabetes, PCOS
- • Diet pattern, physical activity, sleep, occupation
- • Current medications, hypoglycaemia episodes, foot ulcers, erectile dysfunction
Examination
- • BMI, waist circumference, BP both arms, acanthosis nigricans
- • Foot exam — pulses, monofilament, vibration, ulcers, deformity
- • Fundus — diabetic retinopathy; CVS examination
- • Injection sites (lipohypertrophy) if on insulin
Red flags
- • DKA / HHS — vomiting, dehydration, altered sensorium, Kussmaul breathing
- • Foot ulcer with cellulitis or gangrene
- • Severe hypoglycaemia, hypoglycaemia unawareness
Differential diagnosis
- • Type 1 DM (younger, lean, ketosis-prone)
- • LADA, MODY
- • Secondary: pancreatic disease, steroid-induced, Cushing's, acromegaly
Recommended investigations
- • FPG, PPG, HbA1c at diagnosis and 3-monthly
- • Lipid profile, LFT, RFT, urine ACR yearly
- • ECG; fundus screening yearly; foot screening yearly
- • Vitamin B12 if on long-term metformin
Diagnosis
- • Confirm with 2 abnormal tests (or 1 + classic symptoms)
- • Set individualised HbA1c target (usually <7%)
Initial treatment / management
- • Lifestyle: medical nutrition therapy, 150 min/week exercise, smoking cessation
- • Metformin first-line unless contraindicated (eGFR <30)
- • Add SGLT2i or GLP-1 RA early if ASCVD, HF, CKD or BMI >30
- • Statin for ASCVD or age ≥40 with risk factors
Prescription examples
- • Tab Metformin 500 mg PO BD with meals; titrate to 1 g BD
- • Tab Dapagliflozin 10 mg PO OD (if eGFR ≥25, no recurrent UTI)
- • Inj Insulin Glargine 10 U SC HS, titrate by 2 U every 3 d to FPG <130
- • Tab Atorvastatin 20 mg PO HS
Follow-up advice
- • 1–2 weekly initially for glycaemic titration; then 3-monthly HbA1c
- • Annual: foot, fundus, ACR, lipids
- • Self-monitoring blood glucose (SMBG) log review
Patient counselling
- • Diet portion control, complex carbs, fibre, plate method
- • Foot care, daily inspection, well-fitting footwear
- • Hypoglycaemia recognition and 15-15 rule
- • Vaccinations: influenza yearly, pneumococcal, COVID-19
Referral criteria
- • Suspected type 1 DM, MODY, or pregnancy
- • Recurrent severe hypoglycaemia, advanced complications
- • Diabetic foot — urgent multidisciplinary care
Clinical pearls
- • Empagliflozin, dapagliflozin and GLP-1 RAs reduce CV mortality independent of glucose
- • Avoid sulfonylureas in elderly with renal impairment (hypoglycaemia risk)
- • Sick-day rules: never stop insulin, hydrate, monitor ketones
References
- • ADA Standards of Care in Diabetes 2025
- • RSSDI-ESI Clinical Practice Recommendations 2023
- • KDIGO Diabetes in CKD 2022
Educational outpatient guide — verify against local guidelines before clinical use.
