Diabetes mellitus - Type 2

Prescribing Notes:

• Lifestyle management and consideration of remission should be assessed at every review and with any change in medication - consult local pathways where appropriate.  
• The new digital type 2 diabetes remission pathway and the My Diabetes My Way type 2 diabetes remission eLearning resource could be utilised to signpost patients.
• A summary of benefits and cautions for anti-diabetic agents is available in the Type 2 diabetes mellitus: Quality prescribing strategy from the Scottish Government Effective Prescribing and Therapeutics Division.
• Provide Medicines Sick Day Guidance for metformin, SGLT2 inhibitors and sulfonylureas.
• See MHRA Drug Safety Update (March 2020) on SGLT2 inhibitors: monitor ketones in blood during treatment interruption for surgical procedures or acute serious medical illness.

Sulfonylureas 

• Gliclazide is a potent anti-diabetic agent and is associated with weight gain and hypoglycaemia. The risk of hypoglycaemia increases with age. It remains very useful in the following situations:
  • individuals with BMI <25kg/m² (providing type 1 diabetes has been excluded)
  • significant hyperglycaemia at the time of diagnosis of T2D (providing type 1 diabetes has been excluded)
  • steroid-induced diabetes or where pre-existing diabetes worsened by steroids
  • individuals with significant liver or kidney disease
  • certain rare genetic forms of diabetes
• Gliclazide modified-release can be helpful in limited situations where a once daily dose is beneficial, for example patients whose medicines are administered in a single daily visit.
• Glimepiride is a long-acting sulfonylurea and is associated with a greater risk of prolonged hypoglycaemia in older people.

Prescribing Notes:

• Lifestyle management and consideration of remission should be assessed at every review and with any change in medication - consult local pathways where appropriate.  
• The new digital type 2 diabetes remission pathway and the My Diabetes My Way type 2 diabetes remission eLearning resource could be utilised to signpost patients.
• A summary of benefits and cautions for anti-diabetic agents is available in the Type 2 diabetes mellitus: Quality prescribing strategy from the Scottish Government Effective Prescribing and Therapeutics Division.
• Provide Medicines Sick Day Guidance for metformin, SGLT2 inhibitors and sulfonylureas.
• See MHRA Drug Safety Update (March 2020) on SGLT2 inhibitors: monitor ketones in blood during treatment interruption for surgical procedures or acute serious medical illness.

Prescribing Notes:

• Treatment initiation can be recommended by clinicians experienced in the treatment of type 2 diabetes. Refer to local board treatment pathways and associated guidance.
• Lifestyle management and consideration of remission should be assessed at every review and with any change in medication - consult local pathways where appropriate.  
• The new digital type 2 diabetes remission pathway and the My Diabetes My Way type 2 diabetes remission eLearning resource could be utilised to signpost patients.
• A summary of benefits and cautions for anti-diabetic agents is available in the Type 2 diabetes mellitus: Quality prescribing strategy from the Scottish Government Effective Prescribing and Therapeutics Division.
• GLP-1 agonists are approved for use in combination with other antidiabetic medicines. They are not approved for use as monotherapy.   
• Healthcare Improvement Scotland have issued a safety briefing on GLP-1 receptor agonists safety signals (October 2025).
• See MHRA Drug Safety Update (October 2024) for GLP-1 receptor agonists: reminder of the potential side effects and to be aware of the potential for misuse.
• Patients should be reviewed at 6 months and only continue therapy in those with a ≥5 mmol/mol reduction in HbA1c and/or ≥3% reduction in body weight.
• For tirzepatide, the usual starting dose is 2.5mg once weekly. This can be increased after 4 weeks to 5mg once weekly. Higher strengths should be used only where there is a clear ongoing benefit.

Prescribing Notes:

• Lifestyle management and consideration of remission should be assessed at every review and with any change in medication - consult local pathways where appropriate.  
• The new digital type 2 diabetes remission pathway and the My Diabetes My Way type 2 diabetes remission eLearning resource could be utilised to signpost patients.
• A summary of benefits and cautions for anti-diabetic agents is available in the Type 2 diabetes mellitus: Quality prescribing strategy from the Scottish Government Effective Prescribing and Therapeutics Division.

Sulfonylureas - gliclazide

• Gliclazide is a potent ant-diabetic agent and is associated with weight gain and hypoglycaemia. The risk of hypoglycaemia increases with age. It remains useful in the following situations:
  
  • individuals with BMI <25kg/m² (providing type 1 diabetes has been excluded)
  • significant hyperglycaemia at the time of diagnosis of T2D (providing type 1 diabetes has been excluded)
  • steroid-induced diabetes or where pre-existing diabetes worsened by steroids
  • individuals with significant liver or kidney disease
  • certain rare genetic forms of diabetes
• Gliclazide modified-release can be helpful in limited situations where a once daily dose is beneficial, for example patients whose medicines are administered in a single daily visit.

Dipeptidyl-peptidase 4 (DPP4) or ‘Gliptins’

• There have been reports of acute pancreatitis associated with DPP-4 inhibitors. If pancreatitis is suspected, the DPP-4 inhibitor and other potentially suspect medicines should be discontinued.
• See MHRA Drug Safety Update (December 2014) for Dipeptidylpeptidase-4 inhibitors: risk of acute pancreatitis.

Thiazolidinediones or ‘Glitazones’ - pioglitazone

• Pioglitazone is reserved for individuals with contra-indications or intolerance to multiple anti-diabetic agents and where insulin therapy is not desirable.

Prescribing Notes:

• Type of insulin, device and needle gauge and length should be specified. 
• Write the brand name in full to avoid errors such as, for example, administration of Humalog in place of Humalog Mix50.
• When writing prescriptions for insulin the dose should always be written as ‘units’. 
• Insulin is available in 3ml cartridges, 10ml vials, 3ml disposable pens. To support environmentally sustainable prescribing, consider reusable insulin pens and cartridges as first line options. The appropriate pen device must be prescribed with cartridges as not all insulin cartridges fit all pens.
• Humalog Junior Kwikpen, Lyumjev Junior Kwikpen and the reusable Novopen Echo devices allow half unit dose increments.

Prescribing Notes:

• Type of insulin, device and needle gauge and length should be specified. 
• Write the brand name in full to avoid errors such as, for example, administration of Humalog in place of Humalog Mix50.
• When writing prescriptions for insulin the dose should always be written as ‘units’.
• Insulin is available in 3ml cartridges, 10ml vials, 3ml disposable pens. To support environmentally sustainable prescribing, consider reusable insulin pens and cartridges as first line options. The appropriate pen device must be prescribed with cartridges as not all insulin cartridges fit all pens.

Prescribing Notes:

• Type of insulin, device and needle gauge and length should be specified. 
• Write the brand name in full to avoid errors such as, for example, administration of Humalog in place of Humalog Mix50.
• When writing prescriptions for insulin the dose should always be written as ‘units’.
• Insulin is available in 3ml cartridges, 10ml vials, 3ml disposable pens. To support environmentally sustainable prescribing, consider reusable insulin pens and cartridges as first line options. The appropriate pen device must be prescribed with cartridges as not all insulin cartridges fit all pens.

Prescribing Notes:

• Type of insulin, device and needle gauge and length should be specified. 
• Write the brand name in full to avoid errors such as, for example, administration of Humalog in place of Humalog Mix50.
• When writing prescriptions for insulin the dose should always be written as ‘units’.
• Insulin is available in 3ml cartridges, 10ml vials, 3ml disposable pens. To support environmentally sustainable prescribing, consider reusable insulin pens and cartridges as first line options. The appropriate pen device must be prescribed with cartridges as not all insulin cartridges fit all pens.

Prescribing Notes:

• Type of insulin, device and needle gauge and length should be specified. 
• Write the brand name in full to avoid errors such as, for example, administration of Humalog in place of Humalog Mix50.
• When writing prescriptions for insulin the dose should always be written as ‘units’.
• Insulin is available in 3ml cartridges, 10ml vials, 3ml disposable pens. To support environmentally sustainable prescribing, consider reusable insulin pens and cartridges as first line options. The appropriate pen device must be prescribed with cartridges as not all insulin cartridges fit all pens.
• Toujeo Solostar pens allow dosing in 1 unit increments however DoubleStar pens only allow dosing in 2 unit increments.

Prescribing Notes:

• Type of insulin, device and needle gauge and length should be specified. 
• Write the brand name in full to avoid errors such as, for example, administration of Humalog in place of Humalog Mix50.
• When writing prescriptions for insulin the dose should always be written as ‘units’.
• Insulin is available in 3ml cartridges, 10ml vials, 3ml disposable pens. To support environmentally sustainable prescribing, consider reusable insulin pens and cartridges as first line options. The appropriate pen device must be prescribed with cartridges as not all insulin cartridges fit all pens.