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Clinical Pathway

T2DM — Treatment Pathway

Lifestyle, metformin, then cardiorenal-guided escalation

Field: EndocrineCode: EN-01AUpdated: June 2026Reference: RACGP T2DM Handbook / ADS Glycaemic Algorithm
Escalate whenever HbA1c is above the individualised target after ~3 months. In established CVD, heart failure or CKD, an SGLT2 inhibitor or GLP-1 receptor agonist is commonly preferred for its organ-protective benefit — independent of HbA1c.

The stepped-care pyramid

Escalate at each step if the individualised HbA1c target isn't met.

1
Foundation — lifestyle: nutrition review, ≥150min/week activity, 5–10% weight loss where overweight, smoking cessation — started at diagnosis, continued throughout.
2
Metformin: start 500mg, titrate to 1g twice daily as tolerated — first-line unless contraindicated. If contraindicated or not tolerated, pioglitazone is a PBS-listed first-line alternative.
3
Dual therapy — add one agent: SGLT2 inhibitor, GLP-1 receptor agonist, DPP-4 inhibitor, or sulfonylurea — choice guided by the patient's profile, see right.
4
Triple therapy: add another class from the list above. A GLP-1RA + SGLT2i combination is clinically reasonable but has a PBS funding restriction — see the note opposite.
5
Insulin ± GLP-1RA: usually basal insulin first, ± a GLP-1RA, then stepping to premixed or basal-bolus regimens if targets remain unmet.
GLP-1RA + SGLT2i — PBS funding rule. Combining a GLP-1RA and an SGLT2 inhibitor is clinically reasonable, but the PBS generally doesn't subsidise both together for a glycaemic indication. Exception: if the SGLT2i is funded for a non-glycaemic indication (heart failure or CKD) and glycaemic response to it was inadequate, a GLP-1RA can then be added with PBS support. Confirm current wording at pbs.gov.au.

Choosing the next agent

  • Established ASCVD or multiple CV risk factors: an SGLT2 inhibitor or GLP-1RA is commonly preferred for cardiovascular benefit.
  • Heart failure: an SGLT2 inhibitor is commonly the preferred first add-on — see CV-02A.
  • CKD with albuminuria: an SGLT2 inhibitor is commonly preferred for kidney-protective benefit — see REN-01A.
  • Obesity (BMI>30): a GLP-1RA is often favoured for its weight-loss benefit.
  • Hypoglycaemia a concern: an SGLT2 inhibitor or DPP-4 inhibitor carries low intrinsic hypoglycaemia risk.
  • Older or weight-neutral preference: a DPP-4 inhibitor is often well tolerated.

Safety

  • SGLT2 inhibitors: stop temporarily during acute illness, dehydration, or before major surgery — risk of euglycaemic ketoacidosis.
  • Sulfonylureas and insulin carry genuine hypoglycaemia risk — educate on recognition and treatment, especially in older patients.
  • Apply sick-day rules (SADMANS) during illness — see EN-01B / REN-01B.

Red flags / refer

  • HbA1c persistently above target despite optimised triple therapy → consider endocrinology or diabetes educator referral.
  • Recurrent severe hypoglycaemia, or hypoglycaemia unawareness → refer.
  • Suspected type 1 diabetes/LADA, or pregnancy planning/pregnancy → refer.

EN-01A v1.0 · Reviewed Jun 2026 · Review Jun 2027

For health-professional use. Framework: RACGP T2DM Handbook (Nov 2024, upd. Aug 2025); ADS Glycaemic Algorithm (May 2026). Companion sheet: EN-01B T2DM — Targets & Annual Cycle of Care.