Diabetes type 2 in adults — MSF Clinical guidelines

What this guideline says

GMJ summary

This MSF clinical guideline addresses the diagnosis and management of type 2 diabetes in adults, accounting for 90–95% of diabetes cases worldwide. The guideline emphasises a stepwise approach to diagnosis using fasting blood glucose (≥7 mmol/L or ≥126 mg/dL), random blood glucose (≥11 mmol/L or ≥200 mg/dL for venous blood), post-load glucose, or HbA1c (≥6.5%), with confirmation testing required for asymptomatic patients.

Treatment centres on lifestyle modification and metformin as first-line pharmacological therapy (usual dose 1–2 g daily), with escalation to combination therapy with sulfonylureas (glibenclamide for patients under 60, gliclazide for those over 60), and ultimately intermediate-acting insulin if glycaemic targets are not met. Target fasting blood glucose is ≤7 mmol/L (≤126 mg/dL) or HbA1c of 7%, though HbA1c ≤8% is acceptable in certain contexts.

The guideline provides detailed dose titration protocols, surveillance schedules (monthly blood glucose initially, HbA1c every 3–6 months), and emphasises patient education on hypoglycaemia recognition, foot care, and insulin self-administration for appropriate patients. Clinical monitoring includes blood pressure control (<140/80 mmHg) and annual screening for cardiovascular, neurological, and renal complications.

Key points

For clinicians — doses and thresholds as stated in the guideline

1. Diagnosis requires fasting blood glucose ≥7 mmol/L (≥126 mg/dL) on 2 occasions for asymptomatic patients or 1 occasion if symptomatic; alternatively, random venous blood glucose ≥11 mmol/L (≥200 mg/dL), post-load glucose ≥11 mmol/L venous or ≥12.2 mmol/L capillary, or HbA1c ≥6.5%
2. Glycaemic targets: fasting blood glucose ≤7 mmol/L (≤126 mg/dL) or HbA1c 7%; HbA1c ≤8% acceptable in older patients, those with severe hypoglycaemia history, or resource-limited contexts
3. First-line treatment: metformin PO 1–2 g daily, titrated from 500 mg once daily, increasing by 500 mg weekly to maximum 2 g daily (1 g morning and evening)
4. Second-line: add glibenclamide 5 mg twice daily (usual dose) for patients <60 years, maximum 15 mg daily; or gliclazide 40–80 mg twice daily for patients >60 years, maximum 240 mg daily
5. Third-line: continue metformin, replace sulfonylurea with intermediate-acting insulin SC starting at 0.2 IU/kg at bedtime, adjusted by 2–4 units based on morning blood glucose, potentially requiring >1 IU/kg/day
6. Perform urine ketone testing if fasting glucose ≥15 mmol/L (≥270 mg/dL) with symptoms, or fasting/random glucose ≥18 mmol/L (≥325 mg/dL) even without symptoms
7. Surveillance: monthly blood glucose initially, then individualised; HbA1c every 3 months then every 6 months if stable; blood pressure target <140/80 mmHg
8. Patient education essential for all: lifestyle modification (avoid sugared foods, high-fibre diet, physical activity, 5–10% weight loss if BMI ≥25); sulfonylurea/insulin patients must recognise hypoglycaemia/hyperglycaemia signs

Adjustment of intermediate-acting insulin dosage based on blood glucose levels

Table extracted from the guideline

Source: Médecins Sans Frontières, Diabetes type 2 in adults — MSF Clinical guidelines. Reproduced in summary form.

From the guideline

Verbatim

“The closer blood glucose levels remain to these values, the more cardiovascular complications are prevented or delayed.”

Editor’s perspective

Why this matters for Georgia and the region

Applicability

Georgia and the South Caucasus

Questions this guideline answers

Quick answers

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