Clinical Screening, Practice Diagnosis, Guidelines and for the Outpatient Management of Type 2 Diabetes Mellitus among Filipino Adults: Part 2b - Guidelines for the Management of Type 2 Diabetes Mellitus

Diabetes mellitus is a growing public health challenge in the Philippines, with increasing prevalence and delayed diagnosis leading to complications. This Clinical Practice Guideline (CPG) on the Screening and Diagnosis of Type 2 Diabetes Mellitus (T2DM) provides evidence-based recommendations for early detection and timely intervention. It primarily targets adults aged 18 years and older in outpatient settings, guiding general practitioners, specialists, and policymakers. This guideline does not cover Type 1 diabetes, gestational diabetes, or inpatient management. This CPG addresses three key areas: (1) screening for pre-diabetes and T2DM, (2) diagnosis of T2DM, and (3) screening for macrovascular and microvascular complications.

This CPG was developed following a rigorous methodology involving systematic review of existing guidelines using the ADAPTE framework and/or de novo systematic reviews. The GRADE approach was used to assess the quality of evidence and determine the strength of the recommendations. This guideline was developed through a multi-sectoral approach, ensuring representation from medical societies, primary care providers, endocrinologists, nephrologists, cardiologists, policymakers, and patient advocacy groups. The Philippine College of Endocrinology, Diabetes and Metabolism (PCEDM) led the initiative in collaboration with the Department of Health (DOH), the Philippine College of Physicians (PCP), Philippine Heart Association (PHA), Philippine Society of Nephrology (PSN), Philippine Academy of Family Physicians (PAFP), and other key stakeholders. Patients were actively involved in the consensus panel, clinical outcomes prioritization, and focus group discussions to ensure that their perspectives were considered. This guideline was independently developed by the PCEDM and collaborating organizations, with no direct influence from pharmaceutical companies or commercial entities.

This CPG recommends practical strategies for implementation across various healthcare settings which includes the following: (1) dissemination through professional societies, DOH, and academic institutions, (2) promoting the use of the screening algorithms in primary care, (3) integration of the recommendations into DOH’s Universal Health Care framework and PhilHealth reimbursement policies, and (4) public awareness campaigns to promote early screening and diabetes prevention. Furthermore, addressing the identified limitations such as the availability of some tests (e.g., HbA1c in certain regions), need for cost-effectiveness analysis of screening interventions in the Philippine setting, and variability in access to diabetes care is needed.

No.	Recommendations	Certainty of Evidence	Strength of Recommendation
Pharmacologic Therapy
Q1. Should we use metformin as first-line glucose-lowering agent (i.e., monotherapy or base drug for combination therapy) among adult patients with type 2 diabetes mellitus?
1	We recommend metformin as the preferred initial pharmacological agent for type 2 diabetes if it is not contraindicated and is tolerated among adults with T2DM.	Moderate	Strong
2	We recommend metformin as the base drug when combining with other glucose-lowering agents among adults with T2DM.	Moderate	Strong
3	We recommend that initial therapy be based on individual treatment considerations among those with contraindications or intolerance to metformin or based on their specific profile (CHF, ASCVD, CKD).	Low	Strong
Q2. Should we use sulfonylureas, DPP4-inhibitors, SGLT2 inhibitors, thiazolidinediones, GLP-1 receptor agonists and basal insulin among adults with T2DM on metformin after failure to achieve glycemic targets?
4	We recommend any of the oral anti-diabetes medications may be used as a second-line agent among patients with T2DM on metformin after failure to achieve glycemic targets.	Moderate	Strong
5	We recommend the addition of SGLT2 inhibitor as the initial choice of second-line oral agent* among patients with T2DM after failure to achieve glycemic targets. *Remarks: SGLT2 inhibitors have been shown to reduce the risk of heart failure hospitalization, cardiovascular mortality, and all-cause mortality. They also improve health-related quality of life for patients with these conditions. Additionally, SGLT2 inhibitors slow the progression of chronic kidney disease and reduce the risk of end-stage kidney disease in individuals with type 2 diabetes.	Moderate	Strong
6	We recommend a GLP-1 receptor agonist or insulin therapy as add-on therapy among patients with T2DM on metformin after failure to achieve glycemic targets.	High	Strong
7	We recommend the addition of a GLP-1 receptor* agonist as the initial injectable therapy as second-line agent among patients with T2DM on metformin after failure to achieve glycemic targets. *Remarks: GLP-1 RAs have been shown to reduce the risk of stroke, cardiovascular events, and all-cause mortality. They also decrease the progression of macroalbuminuria, promote weight loss, and improve health-related quality of life.	Moderate	Strong
8	We recommend the use of SGLT2 inhibitors, and GLP-1 receptor agonists among patients with T2DM with chronic kidney disease.	High	Strong
9	We suggest the use of sulfonylureas, specifically gliclazide MR*, in resource-limited settings among patients with T2DM with chronic kidney disease. Remarks: *Gliclazide MR may help reduce the incidence of end-stage renal disease in patients with type 2 diabetes, particularly in settings with limited healthcare resources.	Low	Weak
10	We recommend the use of SGLT2 inhibitors among patients with T2DM who are taking metformin and have heart failure.	High	Strong
11	We recommend against the use of thiazolidinediones among patients with T2DM who are taking metformin and have heart failure. Remarks: This recommendation is based on evidence indicating that thiazolidinediones may increase the risk of exacerbating heart failure in patients with type 2 diabetes.	Very low	Strong
12	We recommend the use of GLP-1 receptor agonists among patients with T2DM who are at high risk for stroke or have a previous history of stroke.	High	Strong
13	We recommend the use of either semaglutide* or dulaglutide* among patients with T2DM who are at high risk for stroke or have a previous history of stroke Remarks: Both semaglutide and dulaglutide have been shown to reduce non-fatal and total stroke in patients with type 2 diabetes.	High	Strong
14	We recommend the use of GLP-1 receptor agonist semaglutide 1 mg for weight reduction in patients with T2DM and obesity. Remarks: semaglutide 1 mg and Liraglutide 3 mg demonstrated the greatest magnitude of weight reduction among GLP-1 receptor agonists in patients with type 2 diabetes and obesity.	High	Strong
15	We recommend the use of GLP-1 receptor agonist liraglutide 3 mg for weight reduction in patients with T2DM and obesity. Remarks: semaglutide 1 mg and Liraglutide 3 mg demonstrated the greatest magnitude of weight reduction among GLP-1 receptor agonists in patients with type 2 diabetes and obesity.	Low	Strong
16	We suggest against the use of sulfonylureas, thiazolidinediones, and insulin among patients with obesity and T2DM. Remarks: Sulfonylureas, thiazolidinediones, and insulin are associated with a higher risk of weight gain in patients with obesity and type 2 diabetes, which is why their use is discouraged in this population	Moderate	Weak
17	We recommend against the use of sulfonylureas and thiazolidinediones among patients with T2DM who are at high risk for hypoglycemia	Low	Strong
18	We recommend the use of insulin analogues* (such as glargine U100, glargine U300, and degludec U100) in patients with T2DM requiring insulin. Remarks: Insulin analogues have been shown to reduce the risk of hypoglycemia, particularly nocturnal hypoglycemia, compared to other insulin preparations	Moderate	Strong
Q3. Should we recommend initial oral combination therapy for adults with T2DM with HbA1c >9% or fasting blood sugar (FBS) >250 mg/dL?
19	We recommend oral combination therapy as initial treatment among adults with type 2 diabetes mellitus who have an HbA1c >9% or FBS >250 mg/dL, provided they have no signs or symptoms of ketosis or metabolic decompensation and type 1 diabetes mellitus is not suspected.	Moderate	Strong
Q4. Should we recommend initial combination of injectable therapy combined with oral agent/s for adults with T2DM with HbA1c > 9% or fasting blood sugar (FBS) > 250 mg/dL?
20	We recommend basal insulin therapy in combination with oral glucose-lowering agent/s among adults with T2DM with HbA1c > 9% or fasting blood sugar >250 mg/dL.	Moderate	Strong
21	We recommend the use of glucagon-like peptide-1 (GLP-1) receptor agonists in combination with oral glucose-lowering agent/s among adults with T2DM with HbA1c >9% or fasting blood sugar >250 mg/dL, who have established atherosclerotic cardiovascular disease or are at high cardiovascular risk.	Moderate	Strong
Q5. Should we recommend add-on injectable therapy (basal insulin, GLP-1 receptor agonists, or fixed-ratio combination therapy) among adults with T2DM on 2–3 oral agents and with HbA1c above target?
22	We recommend the use of GLP-1 receptor agonist therapy, basal insulin therapy, OR fixed-ratio combination as an add-on injectable, in combination with oral glucose-lowering agent/s, among adults with T2DM on 2–3 oral agents and with HbA1c above target, following careful consideration of patient-centered factors to further individualize treatment regimens.	Moderate	Strong
23	In resource-limited settings where cost is a major consideration, we recommend the use of basal insulin as an add-on injectable, in combination with oral glucose-lowering agent/s, among adults with T2DM on 2–3 oral agents and with HbA1c above target.	Moderate	Strong
Herbal medications and Supplements
Q6. Should we recommend the use of Momordica charantia [Ampalaya] among adults with T2DM?
24	We neither recommend for nor against the use of Momordica charantia for glycemic control among persons with diabetes. There is no clear evidence that Momordica charantia can improve glycemic control among adults with T2DM at this time.	Very low	Weak
Q7. Should we recommend the use of Chromium picolinate among adults with T2DM?
25	We do not recommend the use of Chromium picolinate or any other Chromium preparation among adults with T2DM.	Very low	Strong
Q8. Should we recommend the use Andrographis paniculata (Serpentina) among adults with T2DM?
26	We do not recommend the use of Andrographis paniculata (Serpentina)* for glycemic control of adults with T2DM. *Remarks: Published studies are mostly in preclinical, phase I or II, searching for its role in the treatment of a lot of other chronic illnesses, including viral infections.	Very low	Strong
Q9. Should we recommend the routine use of vitamin B12 (methylcobalamin or cyanocobalamin) supplementation among adults with T2DM on metformin?
27	We neither recommend for nor against supplementation with methylcobalamin / Vitamin B12 among adults with T2DM on metformin.	Very low	Weak
Q10. Should we recommend the use of Costus igneus (Insulin Plant) among adults with T2DM?
28	We recommend against the use of Costus igneus (Insulin plant) among adults with T2DM.	Very low	Strong
Monitoring and Treatment Targets
Q11. Should we recommend a fasting plasma glucose (FPG) target of 80 to 130 mg/dL to approximate the HbA1c target of <7% among nonpregnant adults with T2DM?
29	We suggest a general fasting plasma glucose (FPG) goal of 80 to 130 mg/dL to approximate the target HbA1c of <7% among nonpregnant adults with T2DM.	Low	Weak
Q12. Should we recommend an HbA1c target of <7% for glycemic control among nonpregnant adults with T2DM?
30	We recommend an HbA1c goal of <7% using an NGSP-certified method among nonpregnant adults with T2DM as long as it can be safely achieved without significant hypoglycemia.	High	Strong
31	We recommend a less stringent HbA1c goal of <8% among nonpregnant adults with T2DM and a history of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications or severe comorbid conditions.	High	Strong
32	We recommend an individualized HbA1c goal taking into account life expectancy, disease duration, presence or absence of complications, comorbid conditions, risk for hypoglycemia and other social determinants of health such as patient support and resources.	High	Strong
Q13. Should we recommend self-monitoring of blood glucose (SMBG) targets of fasting capillary plasma glucose of 80 to 130 mg/dL and 2-hour postprandial capillary plasma glucose of <180 mg/dL to approximate the HbA1c target of <7% among nonpregnant adults with T2DM?
33	We suggest a fasting capillary plasma glucose target of 80 to 130 mg/dL (4.4 to 7.2 mmol/L) and a 2-hour postprandial capillary plasma glucose target of <180 mg/dL (<10.0 mmol/L) in order to achieve an HbA1c of <7.0% among nonpregnant adults with T2DM.	Moderate	Strong
Vaccination and Adjunctive Therapies
Q14. Should we give influenza vaccines annually among adults with T2DM?
34	We recommend routinely giving the influenza vaccine annually to adults with T2DM, ideally from February to June each year before the start of the rainy season in the Philippines (per DOH guidance)	Moderate	Strong
Q15. Should we give pneumococcal vaccines annually among adults with T2DM?
35	We recommend routinely giving both types of pneumococcal vaccine to all adults with T2DM, in the following order: PCV13 or PCV15, followed by PPSV23 after at least 8 weeks (up to a maximum of 1 year). Remarks: ● For adults who have already received PPSV23, they may receive PCV13 or PCV15 after 1 year. ● PPSV23 is given every 5 years until the age of 65. ● When a second PPSV23 dose is used, no additional pneumococcal vaccines are recommended until at least age 65 years. ● For adults aged ≥65 years: one PPSV23 dose only.	Low	Strong
T2DM and specific disease conditions
Q16. Should we recommend specific oral antidiabetic agents or injectable therapies among adults with T2DM and concomitant tuberculosis?
36	We recommend optimization of glycemic control generally using metformin as background therapy in patients with T2DM and concomitant active TB. In the absence of studies, we recommend combined oral anti-diabetes agents or insulin with background metformin therapy.	Low	Strong
37	We recommend the use of insulin in patients with severe hyperglycemia (glycosylated hemoglobin [HbA1c] >10% or fasting plasma glucose [FPG] >300 mg/dL), or in the presence of weight loss and other symptoms of hyperglycemia.	Low	Strong
38	We suggest referral to diabetes clinics for structured care programs for optimization of glycemic control.	Low	Weak
Q17. Should we recommend specific oral antidiabetic agents or injectable therapies among adults with T2DM and metabolic dysfunction-associated steatotic liver disease (MASLD)?
39	We recommend GLP-1 RAs as adjunctive therapy among adults with T2DM and metabolic dysfunction-associated steatotic liver disease (MASLD).	Moderate	Strong
40	We recommend pioglitazone as adjunctive therapy among adults with T2DM and metabolic dysfunction-associated steatotic liver disease (MASLD)	Low	Strong
Q18. Should we recommend specific oral antidiabetic agents or injectable therapies to prevent the occurrence of stroke or its recurrence among adults with type 2 diabetes mellitus and established cardiovascular disease?
41	We suggest the use of GLP1RAs* among individuals with type 2 diabetes mellitus with established cardiovascular disease. *Refers to GLP-1 receptor agonists with demonstrated cardiovascular benefit, specifically dulaglutide or semaglutide.	Low	Weak
Q19. Should we use specific oral antidiabetic agents or injectable therapies among adults with T2DM and obesity?
42	We recommend the use of a GLP-1 receptor agonist as an adjunct to diet and exercise among adults with T2DM and obesity	Moderate	Strong
43	In selecting oral glucose-lowering therapies among adults with T2DM and obesity, we suggest the use of agents that may contribute to weight loss such as metformin and/or SGLT2 inhibitors.	Low	Weak
Q20. Should we recommend specific oral antidiabetic agents or injectable therapies among adults with T2DM and chronic kidney disease (CKD) or end-stage renal disease (ESRD) on dialysis?
44	We recommend the use of SGLT2 inhibitors among adults with T2DM and CKD with an estimated glomerular filtration rate (eGFR) ≥20 mL/min/1.73 m^2.	Strong	High
	Adults with type 2 diabetes mellitus and end-stage renal disease (ESRD) on dialysis should be referred for specialist care for individualized management.	Good Practice Statement
Q21. Should we recommend specific oral antidiabetic agents or injectables among adults with T2DM and cirrhosis or chronic liver disease (CLD)?
45	We suggest the use of metformin and/or sulfonylureas as the initial treatment(s) among adults with T2DM and cirrhosis	Low	Weak
46	We suggest the use of insulin in patients with severe hyperglycemia [glycosylated hemoglobin (HbA1C) >10% or fasting plasma glucose (FPG) >300 mg/dL] among adults with T2DM and cirrhosis	Low	Weak