This document does not replace current clinical guidance and should be read alongside SIGN 116 and 154.1

The expert working group also considered the increasing evidence for newer therapies, sodium-glucose co-transporter-2 inhibitor (SGLT-2i) and glucagon-like peptide 1 receptor agonist (GLP-1RA), since publication of the SIGN guidance and the inclusion of these therapies in other national guidelines (such as NICE2 and ADA3). The expert working group considered the place of these therapies in NHS Scotland, recommending their use.

Polypharmacy in diabetes

Polypharmacy is common for those living with Type 2 diabetes mellitus (T2DM). In addition to management of hyperglycaemia, there is often the prevalence of co-morbidities including:

  • atherosclerotic cardiovascular disease (ASCVD)
  • chronic kidney disease (CKD)
  • heart failure (HF)
  • depression

A polypharmacy review (following the 7-step approach) should ensure optimal management of T2DM and other conditions, and include addressing aggravating lifestyle factors, considering the most appropriate medication at the right dose for that individual, with regular reviews to ensure effectiveness.



Step 1. Aim: what matters to the patient?

Step 2. Need: essential

Step 3. Need: unnecessary

Step 4. Effectiveness

Step 5. Safety

Step 6. Sustainability

Step 7. Patient-centred


Individualisation of glycaemic control

Good glycaemic control is valuable in promoting fewer complications in patients with T2DM, and the figure below shows characteristics and considerations that individuals and clinicians can consider together to assess “what matters to me” when determining individual glycaemic control.

Lifestyle interventions

T2DM treatment should focus on diet and lifestyle interventions at every stage of the patient journey from newly diagnosed to complex care, as the need for increased medication can be driven by excess weight and poor diet.

  • Prevention is better than treatment and so lifestyle and dietary interventions should be supported at all stages.
  • Remission is possible through weight loss and dietary changes supported by local care pathways, including dietitians (see lifestyle interventions and remission).


Pharmacological treatment

  • Metformin remains the first choice for the pharmacological treatment of T2DM (unless contraindicated or not tolerated)
  • Co-morbidities must be considered, particularly
    • atherosclerotic cardiovascular disease (ASCVD)
    • heart failure (HF)
    • chronic kidney disease (CKD).
  • Newer therapies [sodium-glucose co-transporter-2 inhibitor (SGLT-2i) and glucagon-like peptide 1 receptor agonist (GLP-1RA)] have positive outcomes for people with T2DM and are independent of glycaemic control.
  • There is an increased incidence of euglycaemic diabetic ketoacidosis (eDKA) with SGLT-2i and additional advice is provided to support appropriate prescribing of these agents and minimise the risk of harm in their use.
  • Insulin may be required by some people for treatment of T2DM, usually if other pharmacological therapy is no longer effective.

See the table below. 

A PDF of the algorithm below is available here.

Treatment choices in CKD

Treatment options

ACR category A1

normal to mildly increased

(< 3mg/mmol)

ACR category A2

moderately increased

(3 to 30 mg/mmol)

ACR category A3

severely increased

(> 30 mg/mmol)


to highest tolerated dose








(dependent on license) in addition to ACEi/ARB








Other considerations

  • Self-monitoring of blood glucose is recommended for a limited group of people. Use of intermittently scanned or continuous glucose monitoring is increasing, and guidance continues to change to reflect this (see Blood glucose monitoring).
  • In frailty and for the older person: the benefits of intensive treatment should be balanced against the risk of potential hypoglycaemia and its consequences of falls, fractures and hospitalisation. Less stringent HbA1c targets may be appropriate for the frail and older person, in agreement with the individual (see Frailty and older adults). 
  • There is a higher incidence of depression and mental health problems in people with T2DM, which can lead to poorer outcomes for both conditions, and they should not be managed in isolation (see Mental health).
  • Healthcare and prescribing have an environmental impact, which should be minimised wherever possible (see polypharmacy in diabetes and the figure below of medicine waste in Scotland).

Abbreviations, references and further information


ABCD Association of British Clinical Diabetologists
ACEi angiotensin converting enzyme inhibitor
ACR Albumin creatinine ratio
ADA American Diabetes Association
ARB angiotensin receptor blocker
DPP-4i dipeptidyl peptidase-4 inhibitor
eGFR estimated glomerular filtration rate
NICE National Institute for Health and Clinical Excellence
SIGN Scottish Intercollegiate Guidelines Network
SU sulfonylurea

Online resources

EScro Home Page



A list of all references is available in the full guide