Metabolic
How NZ, Australian, and ADA 2024 guidelines differ on treatment sequencing, GLP-1 and SGLT2i access, and cardiovascular risk reduction - and why the comorbidity-first approach that is now international standard is difficult to deliver in NZ primary care.
Scope: type 2 diabetes in adults in primary care. Does not cover type 1 diabetes, gestational diabetes, or inpatient hyperglycaemia management.
Where they agree
Where they diverge
Comparison
| Domain | NZ - BPAC / MoH 2023 | AU - RACGP 2020 | International - ADA 2024 |
|---|---|---|---|
| Diagnosis |
Any one of the following on two separate occasions (or once if symptomatic): HbA1c ≥48 mmol/mol (≥6.5%) Fasting glucose ≥7.0 mmol/L 2-hour OGTT glucose ≥11.1 mmol/L Random glucose ≥11.1 mmol/L with symptoms Prediabetes: HbA1c 41-47 mmol/mol or fasting glucose 6.1-6.9 mmol/L. Annual review recommended. |
Identical WHO-derived thresholds. RACGP also recommends opportunistic screening in Aboriginal and Torres Strait Islander adults from age 18, and in all adults from age 40 with risk factors. Prediabetes management includes structured lifestyle programme referral. | Identical thresholds. ADA 2024 also recognises intermediate categories: impaired fasting glucose (IFG) and impaired glucose tolerance (IGT) as distinct prediabetes states with differing progression risks. Screening recommended from age 35 in adults with overweight or obesity, or earlier in those with additional risk factors. |
| Treatment framework: stepwise vs comorbidity-first |
Largely stepwise in practice, constrained by PHARMAC access: Step 1: Metformin + lifestyle Step 2: Add a sulfonylurea (gliclazide MR, funded) or check SA criteria for SGLT2i or GLP-1 RA Step 3: Dual or triple oral therapy, or insulin BPAC 2023 acknowledges the CV/renal benefit of newer agents and directs clinicians to check PHARMAC special authority criteria. In practice, most patients cannot access GLP-1 RA or SGLT2i early.Access restricted |
RACGP 2020 retains a broadly stepwise approach with metformin first-line, but explicitly recommends prioritising GLP-1 RA or SGLT2i for patients with established CVD, heart failure, or CKD based on PBS-listed indications. This creates a parallel track for high-risk patients alongside the standard glucose-based stepwise approach.PBS access broader than NZ |
ADA 2024 uses a comorbidity-first framework. The initial question is not "what is the HbA1c?" but "does this patient have ASCVD, heart failure, or CKD?" If yes: start or add a GLP-1 RA (for ASCVD, obesity) or SGLT2i (for HF, CKD) as a priority, regardless of current glycaemic control or background therapy. Metformin is still recommended for most patients but is no longer the mandatory prerequisite before cardioprotective agents are considered. |
| GLP-1 receptor agonists |
Funded with Special Authority. Criteria are strict and require verification against the current PHARMAC schedule, but broadly require:SA required Established cardiovascular disease (MI, stroke, or peripheral arterial disease) or very high CV risk, plus failure to achieve adequate control on metformin and at least one other funded agent, with HbA1c above a set threshold. Dulaglutide and semaglutide (injectable) have been funded with SA. Oral semaglutide and tirzepatide are not funded. Confirm current criteria via PHARMAC before prescribing. |
PBS-listed for T2D with established CVD (GLP-1 RA: liraglutide, dulaglutide, semaglutide, exenatide) with comparatively less restrictive access than NZ. Semaglutide weekly injection is PBS-listed for CV indication. Tirzepatide has been or is being added to PBS.PBS Access thresholds are HbA1c-based and do not require prior failure of multiple agents for patients with established CVD. |
ADA 2024 strongly recommends GLP-1 RA in T2D with: Established ASCVD (preferably semaglutide or liraglutide, with proven CV mortality benefit) Obesity or weight management as a treatment goal (semaglutide, tirzepatide) Semaglutide (Ozempic/Wegovy) and tirzepatide (Mounjaro) are the preferred agents for their combined glucose-lowering, weight-reduction, and CV-protective effects. GLP-1 RA are recommended regardless of HbA1c if CV risk profile justifies it.1,2 |
| SGLT2 inhibitors |
Empagliflozin: funded with SA for T2D with established CVD.SA required Dapagliflozin: funded with SA; indicated for T2D with CKD (eGFR ≥25) and for heart failure (HFrEF and HFpEF indications may extend beyond T2D).SA required Both agents require confirmation against the current PHARMAC schedule. Canagliflozin is not funded. The renoprotective and heart failure indications represent the strongest case for accessing these agents through SA criteria in NZ primary care. |
PBS-listed with CV, CKD, and HF indications. Empagliflozin and dapagliflozin are PBS-listed for T2D with established CVD; dapagliflozin has a specific CKD indication (eGFR ≥25). Canagliflozin is also PBS-listed.PBS Access thresholds are less restrictive than NZ: HbA1c criteria apply but prior therapy requirements are less stringent, allowing earlier initiation for high-risk patients. |
ADA 2024 strongly recommends SGLT2i in T2D with: Heart failure with reduced or preserved ejection fraction (dapagliflozin, empagliflozin) CKD with eGFR ≥20 and urine ACR >200 mg/g (dapagliflozin preferred, CREDENCE and DAPA-CKD evidence) Established ASCVD (empagliflozin, canagliflozin) For CKD, SGLT2i should be continued even as eGFR falls, as renoprotective benefit persists at lower eGFR than the glucose-lowering threshold.3,4 |
| HbA1c targets |
General target: <53 mmol/mol (7%) for most adults. Tighter (<48, 6.5%): young patients, newly diagnosed, no CVD or hypoglycaemia risk, long life expectancy. Relaxed (<64, 8%): elderly, frail, limited life expectancy, high hypoglycaemia risk, cognitive impairment, or patient preference. BPAC emphasises that HbA1c alone should not drive therapy escalation; consider weight, renal function, CV risk, and patient values. |
Consistent with NZ. RACGP 2020 uses the same individualised framework. Targets are patient-centred: a person with T2D aged 80 with dementia has a different target to a 45-year-old with newly diagnosed diabetes. Hypoglycaemia avoidance is weighted alongside glucose control in target setting. | ADA 2024: general target <53 mmol/mol (7%). Acknowledges that for many patients, the benefit of tighter control lies in microvascular complication prevention, while cardiovascular protection is better achieved through GLP-1/SGLT2i use than through HbA1c reduction alone. Targets should be individualised and revisited over time. |
| CKD and renal protection |
Annual urine ACR and eGFR for all T2D patients. ACE inhibitor or ARB for T2D with hypertension and/or urine ACR >3 mg/mmol.Funded Dapagliflozin with SA for T2D + CKD (eGFR ≥25, ACR elevated). Referral to nephrology for eGFR <30 or rapidly declining. Finerenone (nonsteroidal MRA) for residual proteinuria on max ACEi/ARB: confirm PHARMAC funding status before prescribing.Check PHARMAC |
Aligned approach. SGLT2i (dapagliflozin) PBS-listed for CKD indication in T2D. ACEi or ARB for proteinuric CKD. Finerenone (Kerendia) has been or is being added to PBS for T2D with CKD and elevated ACR who remain at risk on maximum tolerated ACEi/ARB therapy.PBS | ADA 2024: SGLT2i (dapagliflozin preferred) for T2D + CKD with eGFR ≥20 and ACR ≥200 mg/g; continue even as eGFR falls toward 20. GLP-1 RA provide additional renoprotection. Finerenone is now recommended for T2D + CKD with elevated ACR already on maximum tolerated ACEi/ARB. Combination of SGLT2i and finerenone is under study and may be complementary.3 |
| Sulfonylureas and second-line in NZ |
Sulfonylureas remain the most accessible funded second-line add-on in NZ for patients who do not qualify for SGLT2i or GLP-1 RA special authority. Gliclazide MR is preferred over glibenclamide: lower hypoglycaemia risk, less weight gain, and equivalent glycaemic efficacy.Funded Counsel all patients on sulfonylureas about hypoglycaemia recognition and management. Extra caution in elderly, those with renal impairment, and those who drive or operate machinery. DPP-4 inhibitors (sitagliptin) are funded with SA if sulfonylurea is contraindicated. |
Sulfonylureas (gliclazide) are PBS-listed and remain a reasonable second-line choice where SGLT2i and GLP-1 RA are not indicated or accessible. RACGP 2020 positions them below newer agents for patients with CV risk but acknowledges their practical role. DPP-4 inhibitors (e.g. sitagliptin) are PBS-listed as an alternative with a lower hypoglycaemia profile.PBS | ADA 2024: sulfonylureas have fallen in the treatment hierarchy due to hypoglycaemia risk, weight gain, and lack of CV or renal protection. They remain an option for cost-sensitive settings or where newer agents are inaccessible. If used, gliclazide or glipizide are preferred over glibenclamide (glyburide) in older adults due to lower hypoglycaemia risk. DPP-4 inhibitors (saxagliptin, alogliptin) should be used cautiously in HF due to possible hospitalisation signal. |
| Weight management and bariatric surgery |
Structured lifestyle intervention (reduced calorie diet, at least 150 min/week physical activity) recommended alongside pharmacotherapy at all stages. Refer to a dietitian and diabetes nurse educator where available. Bariatric surgery is not readily accessible through the public system in NZ. Publicly funded surgery is limited to very specific criteria and waiting lists are long. Privately funded options are available but costly. GLP-1 RA for weight management (semaglutide 2.4 mg weekly, Wegovy dose) are not funded for weight management in NZ.Not funded for obesity |
Lifestyle intervention embedded at all steps. Bariatric surgery available through the public system in some states, with variable access. GLP-1 RA (semaglutide at higher doses) have been or are being approved and PBS-listed for obesity management, broadening access beyond the T2D indication.Broader obesity access than NZ | ADA 2024: metabolic/bariatric surgery recommended to be discussed for all patients with T2D and BMI ≥35 kg/m² (≥32.5 in Asian populations) and considered for BMI 30-34.9 if glycaemic goals are not achieved with lifestyle and pharmacotherapy. Semaglutide (2.4 mg) and tirzepatide produce 15-22% body weight reduction and are transforming weight management alongside surgery. Weight loss of 5-15% significantly improves glycaemic control and can induce remission in early T2D.5 |
| Glucose monitoring: SMBG and CGM |
Self-monitoring of blood glucose (SMBG): funded for patients on insulin or sulfonylureas. Frequency guided by therapy type and individual need.Funded CGM: PHARMAC funds continuous glucose monitoring very selectively. As of 2023, funded access is primarily limited to patients with type 1 diabetes meeting specific criteria; patients with T2D on insulin are generally not funded for CGM. Confirm current PHARMAC criteria as they have been evolving.Very limited in T2D |
SMBG funded for insulin users and those on sulfonylureas. CGM access in AU has broadened significantly: CGM is PBS-listed for type 1 diabetes, and subsidised access for T2D on intensive insulin is available. AU has a more generous CGM funding pathway than NZ for T2D patients on insulin.Broader CGM access | ADA 2024: real-time CGM recommended for all people with diabetes using insulin, including T2D. CGM improves HbA1c, reduces hypoglycaemia events, and reduces glycaemic variability in T2D patients on insulin.6 Intermittently scanned CGM (Flash, e.g. FreeStyle Libre) is an acceptable alternative where real-time CGM is not available or preferred. For T2D not on insulin, CGM may support behaviour change and self-management. |
| Cardiovascular risk management |
PREDICT-CVD (NZ cardiovascular risk calculator) is the standard tool for absolute CV risk assessment. Use it to guide statin therapy, BP targets, and antiplatelet decisions. High-intensity statin for established CVD. Statin therapy for T2D patients with ≥5-year CV risk above threshold. BP target generally <130/80 mmHg. Aspirin not recommended for primary prevention (net harm in most patients); consider in established CVD.Statins funded |
Similar approach to CV risk-based statin prescribing and BP targets. Aspirin not recommended for primary prevention of CVD in T2D. ACEi or ARB for patients with T2D and hypertension. RACGP 2020 aligns with Australian CVD prevention guidelines for statin thresholds. | ADA 2024: high-intensity statin for all adults with T2D aged 40-75 with CVD risk factors (LDL-lowering by ≥50%). Aspirin: not recommended for primary prevention in T2D (increased bleeding risk outweighs CV benefit based on ASCEND and ARRIVE trials). BP target <130/80 mmHg for most patients with T2D. ACEi or ARB preferred antihypertensive agents in T2D with CKD or proteinuria. |
NZ clinical context
PHARMAC funding, the comorbidity-first gap, and equity considerations
Most patients with T2D in NZ will follow a funded pathway that looks quite different from ADA 2024 recommendations. The practical sequence is:
PHARMAC special authority criteria for SGLT2i and GLP-1 RA are updated periodically and have been broadened since both drug classes were first funded. A patient who did not qualify two years ago may qualify today. Specifically:
T2D prevalence among Maori and Pacific peoples is two to four times higher than in NZ Europeans, onset occurs at a younger age, complications develop earlier, and rates of end-stage renal disease and cardiovascular death are substantially higher.7 This is not primarily a biological difference: it reflects upstream determinants of health alongside access barriers.
The restricted access to cardioprotective agents in NZ therefore has a disproportionate impact on Maori and Pacific patients, who are most likely to benefit from early GLP-1 RA or SGLT2i use for renal and cardiovascular protection and least able to absorb the cost of unfunded alternatives. When a Maori or Pacific patient with T2D and CKD cannot access dapagliflozin because the SA criteria are just out of reach, that is both a clinical problem and an equity problem. Document these gaps and advocate accordingly.
Long-term metformin use reduces vitamin B12 absorption in up to 30% of patients.8 The effect is dose-dependent and may be present for years before it becomes symptomatic. Check B12 at baseline and at least annually in patients on metformin for more than two years, or earlier if there is any peripheral neuropathy. Supplementation is straightforward if deficiency is identified.
Initiation of basal insulin (glargine, starting at 10 units nightly and titrating by 2 units every 3 days to a fasting glucose target of 4-7 mmol/L) is within scope for most GPs. Diabetes nurse educators (where available) are an important resource for titration support and education. If a patient on basal insulin remains above HbA1c target, review injection technique and timing before stepping up to prandial insulin; often the problem is technique rather than dose.
Bottom line for NZ practice
What this means in the consulting room
Sources