Management of non-insulin therapy in acutely unwell patients with type 2 diabetes 

Metformin

• Acute kidney injury (AKI):
  • Stop if eGFR<30ml/minute/1.73m².
  • Reduce dose to 500mg twice daily if eGFR 30-44ml/minute/1.73m². 
• Withhold if severe sepsis, especially if lactate >5mmol/L.
• Withhold if diarrhoea and vomiting. 

'Gliptins' (DPP-4i) or 'glutides' (GLP-1 mimetics) 

• Withhold if diarrhoea and vomiting. 
• Dose-adjust in AKI (as per BNF).

'Gliflozins' (SGLT-2i) 

• Withhold if septic (especially urosepsis).
• Withhold if pre-operative.
• Withhold if diarrhoea and vomiting.
• Withhold if dehydrated or AKI.
• Consider euglycaemic DKA if patient is unwell (check venous blood glucose (VBG) and blood ketones).

Pioglitazone  

Discontinue if acute fluid overload (e.g. heart failure). 

Gliclazide 

• Withhold or reduce dose if AKI, HbA1c <53mmol/mol, or reduced oral carbohydrate intake. 
• Consider increasing the dose if hyperglycaemic (e.g. steroids - see management of steroid-induced hyperglycaemia), review dose prior to discharge.

For more information on management of non-insulin therapy in the perioperative period, please see the Perioperative Guideline for the Management of Diabetes.

Guideline reviewed: February 2025

Page updated: November 2025