Type 2 diabetes — the AU general practice approach

What type 2 diabetes is and why it matters in Australian general practice

Type 2 diabetes mellitus (T2DM) is the most common form of diabetes in Australia. Around 1.3 million Australians carry a diagnosis — about 5% of adults — and a further 25% are estimated to have pre-diabetes. The condition is involved in roughly 12% of all general practice consultations, making it one of the defining challenges of Australian general practice.

T2DM arises from the combination of insulin resistance — where liver, muscle, and fat cells respond inadequately to insulin — and progressive beta-cell failure, which reduces the pancreas’s capacity to compensate. Sustained hyperglycaemia drives microvascular complications (diabetic retinopathy, nephropathy, neuropathy) and accelerates macrovascular disease. The disease burden falls disproportionately on Aboriginal and Torres Strait Islander Australians, whose prevalence is three to four times higher than the general population with earlier onset — commonly presenting in the third and fourth decades of life.

The RACGP / Diabetes Australia Management of Type 2 Diabetes Handbook (2024) and the Australian T2DM Management Algorithm (June 2024) provide the primary evidence framework used here, supplemented by eTG Endocrinology, AMH, and the Heart Foundation 2023 CV risk guideline.

A. Core clinical — the AU general-practice framework

Diagnostic criteria

T2DM is diagnosed by any one of the following, confirmed with a repeat test on a different day when there are no unequivocal hyperglycaemia symptoms:

• HbA1c ≥6.5% (48 mmol/mol) — convenient; fasting not required; invalidated by haemoglobin disorders, severe anaemia, recent blood transfusion, or pregnancy
• Fasting plasma glucose ≥7.0 mmol/L
• Random plasma glucose ≥11.1 mmol/L with classic symptoms (polyuria, polydipsia, unexplained weight loss, lethargy)
• 2-hour 75 g OGTT ≥11.1 mmol/L

Pre-diabetes is defined as HbA1c 39–47 mmol/mol (5.7–6.4%), fasting glucose 6.1–6.9 mmol/L, or 2-hour OGTT 7.8–11.0 mmol/L. Approximately 25–50% of people with pre-diabetes progress to T2DM within 5–10 years without intervention; intensive lifestyle modification reduces this progression by approximately 58% — as demonstrated in the Diabetes Prevention Program (NEJM 2002).

History and risk stratification

Key risk factors for T2DM include: age ≥45 (start screening earlier in high-risk groups), a first-degree family history, Aboriginal and Torres Strait Islander background, Pacific Islander or South Asian background, BMI ≥25 kg/m² (lower thresholds apply in South Asian populations), previous gestational diabetes, polycystic ovary syndrome (PCOS), hypertension, dyslipidaemia, and obstructive sleep apnoea.

Symptoms in T2DM are often absent or subtle at diagnosis — polyuria, polydipsia, fatigue, recurrent skin or urinary infections, and blurred vision can all occur. Many people are picked up incidentally through health assessments or incidental pathology.

Mental health comorbidity — especially depression and anxiety — affects approximately 30% of people with T2DM and is bidirectional. Use PHQ-9 at diagnosis and annually.

Examination

Examine for: BMI and waist circumference; blood pressure (seated and standing — to screen for autonomic neuropathy); peripheral pulses (femoral, popliteal, dorsalis pedis, tibialis posterior); comprehensive foot examination (10 g monofilament sensation, vibration at great toe, ankle reflexes, foot deformity, skin and nail changes, any ulceration); acanthosis nigricans (marker of insulin resistance); thyroid; and signs of secondary endocrine causes (Cushingoid features, acromegalic features).

Investigations at diagnosis

The initial workup includes:

• HbA1c (and fasting plasma glucose if needed)
• Full blood count
• Fasting lipid profile
• Urea, electrolytes, creatinine (UEC), and eGFR
• Urine albumin-to-creatinine ratio (UACR — microalbuminuria screen)
• Liver function tests
• TSH
• B12 (especially if already on metformin for pre-diabetes)
• 12-lead ECG
• Cardiovascular risk calculation via the Heart Foundation 2023 Australian tool (cvdcheck.org.au)

Arrange eye review via KeepSight or optometrist/ophthalmologist at diagnosis. Register with NDSS for subsidised consumables.

Differential diagnosis

Distinguish T2DM from:

• T1DM: younger or lean presentation, ketosis-prone, rapid deterioration — anti-GAD, IA-2, and zinc transporter 8 antibodies positive
• LADA (latent autoimmune diabetes of adulthood): adult onset, lean build, rapid progression to insulin requirement, anti-GAD positive — endocrinology referral
• MODY (maturity-onset diabetes of the young): autosomal dominant family history, age under 25, lean, atypical course — genetic panel testing
• Secondary diabetes: steroid-induced, antipsychotic-induced (atypical antipsychotics), pancreatic disease (chronic pancreatitis, pancreatectomy, pancreatic cancer), Cushing’s syndrome, acromegaly, haemochromatosis (check ferritin and transferrin saturation if clinical suspicion)
• Drug-induced: tacrolimus, antiretrovirals

Lifestyle intervention — first-line for everyone

Lifestyle intervention is the foundation of T2DM management regardless of what pharmacotherapy is commenced.

Diet: RACGP/Diabetes Australia 2024 supports Mediterranean, DASH, low-carbohydrate, and very low-calorie diet (VLCD, approximately 800 kcal/day for up to 12 weeks under supervision) approaches. The DiRECT trial (Lancet 2018) demonstrated approximately 46% of participants achieved diabetes remission at 12 months with a dietitian-supported total diet replacement programme. Refer to a dietitian via the GPCCMP allied health pathway.

Physical activity: At least 150 minutes per week of moderate aerobic activity (brisk walking, cycling, swimming) plus two resistance-training sessions per week. Reducing sedentary time independently improves metabolic outcomes.

Weight loss: A 5–10% weight reduction produces meaningful glycaemic improvement. Substantial weight loss (≥15%) in the first five years of T2DM can support full remission in motivated individuals.

Alcohol: Per NHMRC 2020 alcohol guidelines, no more than 10 standard drinks per week and no more than 4 in any single session. Alcohol predisposes to hypoglycaemia in insulin-treated patients — an important safety point.

Smoking: Smoking sharply accelerates cardiovascular and renal risk in T2DM. Cessation is essential; offer pharmacotherapy (varenicline or NRT) at every opportunity.

Sleep and mental health: Obstructive sleep apnoea is highly prevalent in T2DM and worsens insulin resistance — screen using STOP-BANG. Treat depression and anxiety actively using PHQ-9 and GAD-7; these conditions worsen glycaemic self-management if untreated.

First-line pharmacotherapy — metformin

Metformin is first-line unless contraindicated (eGFR <30 mL/min/1.73 m², severe hepatic impairment, or contrast media administration within 24–48 hours). Start at 500 mg twice daily with food and titrate weekly to 1 g twice daily over 4 weeks. Modified-release formulations (Diabex XR, Glucophage XR) are better tolerated gastrointestinally. Reduce dose to 1 g/day total when eGFR 30–45. Check B12 annually on long-term metformin — impaired absorption is common and can present as neuropathy or macrocytic anaemia.

B. Pharmacotherapy — choosing the second agent

Indication-based second agent selection

Per the RACGP/Diabetes Australia 2024 algorithm, the second agent is driven by the individual’s complication and comorbidity profile rather than simply by glucose level:

Established CVD or very high cardiovascular risk → SGLT2 inhibitor or GLP-1 receptor agonist: Empagliflozin reduced CV death and hospitalisation for heart failure versus placebo in the EMPA-REG OUTCOME trial (NEJM 2015). Liraglutide reduced major adverse cardiovascular events in LEADER (NEJM 2016) and semaglutide in SUSTAIN-6 (NEJM 2016).

Heart failure (any ejection fraction) → SGLT2 inhibitor: Dapagliflozin reduced hospitalisation for heart failure and CV death in DAPA-HF (NEJM 2019) regardless of diabetes status, and in the preserved-ejection-fraction setting in DELIVER (NEJM 2022). SGLT2 inhibitors are now a cornerstone of heart failure management across all ejection fraction ranges.

Chronic kidney disease with albuminuria (UACR ≥3.0 mg/mmol) → SGLT2 inhibitor: DAPA-CKD (NEJM 2020) and EMPA-KIDNEY (NEJM 2023) confirmed kidney protection independent of diabetes status. For those with eGFR ≥25, UACR ≥3.0, and serum potassium ≤4.8 mmol/L, the non-steroidal mineralocorticoid receptor antagonist finerenone (Kerendia) provides additive renal and cardiovascular protection — FIDELIO-DKD (NEJM 2020). Finerenone requires Authority Required PBS prescription.

Obesity (BMI ≥30, or ≥27 with complications) → GLP-1 receptor agonist: Semaglutide produces 10–15% body weight reduction alongside significant glycaemic benefit. Dulaglutide (REWIND) and liraglutide are PBS-listed alternatives for T2DM.

No specific indication → DPP-4 inhibitor, sulfonylurea, or pioglitazone: DPP-4 inhibitors (sitagliptin, linagliptin, vildagliptin) are weight-neutral and carry low hypoglycaemia risk. Sulfonylureas (gliclazide, glimepiride) are inexpensive and effective but carry hypoglycaemia and moderate weight-gain risk. Pioglitazone is effective but contraindicated in heart failure and associated with fracture risk in women.

Tirzepatide in Australia — a current note

Tirzepatide (Mounjaro), a dual GIP/GLP-1 receptor agonist, was recommended for PBS listing by the PBAC, but Lilly declined the listing in April 2026 citing risk-sharing terms. Tirzepatide remains a private prescription only in Australia as of mid-2026 — available at significant cost without subsidy. The TGA issued a December 2024 safety update advising that oral contraceptive efficacy may be reduced during tirzepatide initiation and dose escalation — advise use of barrier or non-oral contraception at initiation and for 4 weeks after each dose increase.

HbA1c targets — individualised

Targets must be tailored to the person, not applied universally:

• ~7.0% (53 mmol/mol): reasonable for most adults
• ~6.5% (48 mmol/mol): younger adults, short disease duration, low hypoglycaemia risk, no significant complications
• ≥8.0% (64 mmol/mol): older adults, frailty, significant hypoglycaemia risk, dementia, limited life expectancy

The ACCORD trial (NEJM 2008) found intensive glucose lowering (mean HbA1c ~6.4%) increased all-cause mortality in older adults with established CVD compared with standard control — confirming that individual target-setting is not optional.

SGLT2 inhibitor safety points

Side effects to counsel include: vulvovaginal candidiasis and balanitis (5–10% — hygiene advice and early treatment); volume depletion (hold or reduce diuretics and antihypertensives in acute illness); and euglycaemic DKA (rare but serious — occurs despite near-normal glucose, precipitated by very low carbohydrate intake, prolonged fasting, illness, or surgery). Hold SGLT2 inhibitors 24–72 hours before elective surgery and during prolonged fasting.

GLP-1 receptor agonist safety points

Nausea and vomiting are common at initiation (titrate slowly, usually over 4–8 weeks). Rare but important risks: acute pancreatitis (advise patients to stop and seek review with severe abdominal pain) and gallstone formation. Hold for at least one week before elective anaesthesia given gastroparesis risk and aspiration concerns. GLP-1 receptor agonists should be avoided in pregnancy — ceasing at least two months before conception.

Insulin initiation

Basal insulin (glargine, detemir, or degludec) is added when multi-agent regimens are inadequate. Start at 10 units at bedtime; titrate by 2 units every 3 days to achieve fasting glucose <7.0 mmol/L, watching for hypoglycaemia. Involve a credentialled diabetes educator (CDE) — NDSS funds access. Driving requirements under Austroads change with insulin therapy; document and counsel.

Cardiovascular risk reduction

Beyond glucose management, comprehensive CV risk reduction is integral. Per the Heart Foundation 2023 guideline: high-intensity statin therapy for most adults with T2DM aged ≥40 with elevated CV risk; blood pressure target <130/80 mmHg (relaxed to <140/90 in older or frail adults); and antiplatelet therapy for secondary prevention only. The ASCEND trial (NEJM 2018) confirmed aspirin for primary prevention in T2DM without CVD increases bleeding risk without sufficient benefit.

C. Monitoring — the annual cycle of care

Per the RACGP/Diabetes Australia 2024 Handbook, ongoing review follows a structured schedule. These checks are typically incorporated into the GPCCMP.

Parameter	Frequency
HbA1c	Every 3 months until stable at target, then every 6 months
Blood pressure	Every visit
Fasting lipids	Annually
UACR + eGFR	Annually
Foot examination	Annually (more often if neuropathy, peripheral vascular disease, or prior ulcer)
Eye examination	Every 1–2 years via KeepSight or ophthalmologist; more often if retinopathy present
B12	Annually if on metformin
Mental health screen (PHQ-9)	Annually and at symptomatic presentations
Weight / BMI	Every visit
Vaccination status	Annual influenza; Prevenar 20 (one dose in adults); COVID-19 per ATAGI; RSV recommended from age ≥60 per 2024 handbook update
Medication review	Every visit

D. Australian operations — MBS, PBS, and subsidised care

MBS items in the T2DM pathway

Standard consultation items 23, 36, and 44 apply by length. Key additional structures:

• GPCCMP (GP Chronic Condition Management Plan) — items 965 (preparation) and 967 (review), replacing the former GPMP (721) and TCA (723) from 1 July 2025. T2DM is the prototypical qualifying condition. Enables 5 allied health sessions per year (10 for Aboriginal and Torres Strait Islander patients) — dietitian, exercise physiologist, podiatrist, credentialled diabetes educator (CDE), and optometrist
• Heart Health Check — item 699, available annually for adults ≥30 (≥18 for ATSI)
• ATSI Health Assessment — item 715, every 9 months for any Aboriginal or Torres Strait Islander patient of any age
• 75+ Health Assessment — item 705, annual comprehensive review for older adults
• Better Access Mental Health Care Plan — items 2715/2717 for the approximately 30% of people with T2DM who also experience depression or anxiety
• Practice nurse follow-up — item 10997

PBS authority status

Medication class	PBS status
Metformin	General schedule (unrestricted)
Sulfonylurea (gliclazide, glimepiride)	General schedule
DPP-4 inhibitors (sitagliptin, linagliptin, vildagliptin)	Authority Required (Streamlined) — T2DM combination therapy
SGLT2 inhibitors (empagliflozin, dapagliflozin, ertugliflozin, canagliflozin)	Authority Required (Streamlined) — T2DM combination, heart failure, CKD with albuminuria; criteria expanded substantially in 2024–25
GLP-1 receptor agonists (liraglutide, dulaglutide, semaglutide injectable and oral)	Authority Required (Streamlined) — T2DM; specific HbA1c failure criteria apply
Tirzepatide (Mounjaro)	Not PBS-listed as of mid-2026 (Lilly declined PBAC recommendation April 2026)
Finerenone (Kerendia)	Authority Required — CKD with T2DM and albuminuria, specific eligibility
Insulin (multiple analogues)	General schedule

NDSS and KeepSight registration

Register all people with T2DM with the National Diabetes Services Scheme (NDSS) at diagnosis — this provides subsidised consumables including blood glucose monitoring strips, lancets, needles, and glucagon emergency kits. Continuous glucose monitoring (CGM) access via NDSS in T2DM is available for those with specific indications including intensive insulin therapy and hypoglycaemia unawareness.

Register with KeepSight — the national diabetes eye care registry — which sends automated reminders for eye reviews and tracks national coverage.

Driving with T2DM

Insulin-treated T2DM requires compliance with Austroads standards. A severe hypoglycaemia event (requiring third-party assistance) triggers reporting requirements in some states. Document counselling about self-monitoring and driving restrictions clearly in the record.

E. Special populations

Aboriginal and Torres Strait Islander Australians

Prevalence is three to four times higher than the general population, with onset typically 10–20 years earlier. The ATSI Health Assessment (item 715, every 9 months) is the key entry point for systematic review. CV risk calculation applies from age 30 in ATSI patients rather than age 45 for the general population. The Closing the Gap PBS co-payment program significantly reduces medication costs for ATSI patients with chronic conditions or risk factors — voluntary registration via Services Australia.

Engage Aboriginal Health Workers and Aboriginal Liaison Officers in diabetes management planning. Where available, use community-controlled health services for culturally safe, holistic care.

Older adults and frailty

Relax HbA1c targets (≥8% or higher in frailty) — hypoglycaemia in older adults causes falls, fractures, acute cardiac events, and cognitive impairment. Review medications for hypoglycaemia risk; deprescribing sulfonylureas and insulin in frail patients is often appropriate. Use SGLT2 inhibitors carefully in those at elevated risk of volume depletion and urinary tract infections.

Pregnancy and pre-pregnancy planning

Pre-pregnancy planning targets HbA1c <6.5% and requires cessation of teratogenic medicines: statins, ACE inhibitors and ARBs, SGLT2 inhibitors, GLP-1 receptor agonists, and most non-insulin agents. Switch to insulin (with or without metformin depending on local protocol) and start high-dose folic acid 5 mg daily. Specialist obstetric/diabetes co-management is essential throughout pregnancy.

MODY and LADA

Suspect MODY in anyone under 25 with autosomal dominant family history of early-onset diabetes, lean build, and atypical disease course — genetic panel testing is available. Suspect LADA when an apparent T2DM patient is lean, progresses rapidly to insulin dependence, or has anti-GAD antibodies positive. Both diagnoses warrant endocrinology referral and significantly alter management.

Metabolic surgery

For people with BMI ≥35 with comorbidities (or ≥30 with T2DM in some programs), metabolic (bariatric) surgery remains the most durable pathway to remission — with significantly greater and more sustained HbA1c improvement than lifestyle and pharmacotherapy alone. Referral to a bariatric surgery service for shared decision-making is appropriate in eligible, motivated patients.

When to escalate

Emergency / same-day (call 000 or send to Emergency Department):

• Diabetic ketoacidosis (DKA) — abdominal pain, vomiting, dyspnoea, ketones elevated regardless of glucose level
• Euglycaemic DKA — same symptoms but blood glucose near-normal, particularly in SGLT2 inhibitor users
• Hyperosmolar hyperglycaemic state (HHS) — very high glucose (often >30 mmol/L), marked dehydration, altered consciousness, typically elderly
• Severe hypoglycaemia with impaired consciousness or requiring third-party assistance
• Acute foot infection, necrotising fasciitis, or suspected Charcot foot
• Sudden vision loss, floaters, or new retinal haemorrhage — urgent ophthalmology

Routine specialist referral:

• Suspected T1DM, LADA, or MODY → endocrinology
• Complex insulin regimen or HbA1c persistently above individualised target
• Pregnancy with T2DM → obstetric diabetes service (endocrinologist and obstetrician)
• Advancing CKD (eGFR declining towards <30 mL/min/1.73 m²) → nephrology
• High-risk foot (neuropathy, ischaemia, deformity, prior ulcer) → high-risk foot service or vascular surgery
• Consideration of metabolic surgery → bariatric surgery service

What this article is and is not

This is general health information drawn from current Australian general practice guidelines — the RACGP / Diabetes Australia 2024 Handbook, eTG Endocrinology, AMH, and the Heart Foundation 2023 CV risk guideline. It is not personal medical advice and does not create a doctor–patient relationship. Decisions about diagnosis, treatment targets, and medication selection are made with your own general practitioner and treating team based on your individual clinical history, values, and circumstances.

For consumer-friendly resources: Diabetes Australia, NDSS, KeepSight, HealthDirect — Type 2 diabetes, Better Health Channel.

For mental health support: Beyond Blue 1300 22 4636, Lifeline 13 11 14.

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Sources cited

1. RACGP / Diabetes Australia — Management of Type 2 Diabetes: A Handbook for General Practice (2024)
2. Therapeutic Guidelines (eTG) — Endocrinology: Diabetes
3. Australian Medicines Handbook (AMH)
4. Heart Foundation — 2023 Australian Guideline for assessing and managing CV risk
5. NHMRC — Australian Guidelines to Reduce Health Risks from Drinking Alcohol (2020)
6. Diabetes Australia
7. NDSS — National Diabetes Services Scheme
8. KeepSight — national diabetes eye screening registry
9. TGA — Updated contraception advice for tirzepatide (December 2024)
10. HealthDirect — Type 2 diabetes
11. Better Health Channel — Type 2 diabetes
12. Lean ME et al. — DiRECT trial (Lancet 2018)
13. Zinman B et al. — EMPA-REG OUTCOME (NEJM 2015)
14. Marso SP et al. — LEADER (NEJM 2016)
15. Marso SP et al. — SUSTAIN-6 (NEJM 2016)
16. McMurray JJV et al. — DAPA-HF (NEJM 2019)
17. Solomon SD et al. — DELIVER (NEJM 2022)
18. Heerspink HJL et al. — DAPA-CKD (NEJM 2020)
19. EMPA-KIDNEY Collaborative Group (NEJM 2023)
20. Bakris GL et al. — FIDELIO-DKD (NEJM 2020)
21. ACCORD Study Group (NEJM 2008)
22. ASCEND Study Collaborative Group (NEJM 2018)
23. Knowler WC et al. — DPP trial (NEJM 2002)