Medical Academic (MA): How do you individualise glycaemic targets for patients with T2DM in primary care, and which factors most influence your target setting?

Dr Ankia Coetzee (AC): Glycaemic targets should always be individualised using a patient-centred approach that balances the benefits of glucose lowering against the risks of hypoglycaemia, treatment burden, and comorbid disease. In general, an HbA1c target of <7% is appropriate for many adults with T2DM.

Tighter targets (eg <6.5%) may be appropriate in younger patients with recent-onset disease, long life expectancy, and low hypoglycaemia risk. Less stringent targets (eg 7.5–8% or higher) are more appropriate in older adults, frailty, advanced complications, limited life expectancy, or high hypoglycaemia risk.

Key influencing factors include age, duration of diabetes, cardiovascular (CV) and renal disease, hypoglycaemia risk, treatment complexity, psychosocial context, and patient preference. Increasingly, targets are considered within the broader context of metabolic health and quality of life rather than glucose alone.

MA: What is your stepwise approach to initiating pharmacological treatment for T2DM, and how do you decide between first-line options such as metformin, SGLT2 inhibitors, or GLP-1 receptor agonists?

AC: Lifestyle intervention remains the foundation of care and should be initiated at diagnosis. Pharmacological therapy is increasingly individualised based on comorbidities rather than glucose alone.

Metformin is appropriate first-line therapy for many patients due to its efficacy, safety, cost-effectiveness, and long-term evidence base. However, in patients with established CV disease, heart failure (HF), chronic kidney disease (CKD), or obesity, early use of sodium-glucose co-transporter 2 inhibitors (SGLT2i) or glucagon-Like peptide-1 receptor agonists (GLP-1RA) may be appropriate, even as first-line therapy.

GLP-1RA are preferred when weight loss and CV risk reduction are priorities. SGLT2i are preferred when cardiorenal protection is the main goal, particularly in heart failure or chronic kidney disease.

Overall, modern treatment decisions are increasingly driven by comorbidity profiles and organ protection rather than glucose lowering alone.

MA: How do comorbidities such as CV disease, CKD, obesity, or HF influence your choice of glucose-lowering therapy?

AC: Comorbidities are central to treatment selection. In established CV disease, GLP-1RA and SGLT2i with proven benefit should be prioritised. In HF, particularly HF with reduced ejection fraction, SGLT2i are preferred due to reductions in hospitalisation and CV mortality.

In CKD, SGLT2i form foundational therapy due to renoprotective effects, with GLP-1RA added where additional metabolic or CV benefit is needed.

In obesity, GLP-1RA and dual incretin therapies are particularly useful due to their effects on both glycaemia and weight reduction. Therapies associated with weight gain or hypoglycaemia, such as sulfonylureas and insulin, should be used cautiously in these groups.

MA: At what point do you consider escalating therapy, and how do you decide whether to increase doses, add a second oral agent, or introduce combination therapy?

AC: Therapy should be reassessed about every three-months, or sooner if control is clearly inadequate. Escalation is considered when HbA1c remains above target despite adherence and lifestyle intervention.

If a patient is not yet on maximal tolerated doses, dose optimisation may be appropriate. However, when HbA1c remains above target or comorbidities require organ protection, early combination therapy is often preferred.

A key principle is avoiding therapeutic inertia, which is the failure to intensify treatment when indicated. Delays in escalation contribute to prolonged hyperglycaemia and increased risk of complications. Early and proactive intensification improves long-term outcomes and may confer a ‘legacy effect’ of sustained benefit.

MA: How do you approach the initiation of insulin in T2DM, and what clinical indicators suggest that insulin therapy is required?

AC: Insulin should be considered when there is significant insulin deficiency or severe hyperglycaemia. Indicators include HbA1c >10%-11%, symptomatic hyperglycaemia, weight loss, ketosis, or failure of non-insulin therapies. Basal insulin is usually initiated first, often alongside agents with CV or renal benefit. Increasingly, GLP-1RA and dual incretin therapies may delay or reduce insulin requirements.

Patient education is essential, including injection technique, hypoglycaemia awareness, and glucose monitoring. Continuous glucose monitoring is increasingly valuable in optimising insulin therapy and reducing burden.

MA: What key components should be included in a comprehensive treatment plan for T2DM in primary care beyond medication alone?

AC: A holistic treatment approach should address cardiometabolic risk using an ABCDE framework:

• A: HbA1c and adiposity (glucose and weight)
• B: Blood pressure
• C: Cholesterol and contraception in females
• D: Diet and drugs (including SGLT2i or GLP-1RA based on comorbidities, nutrition counselling)
• E: Exercise, education, extras (vaccinations, screening, psychosocial support)
• S: Smoking cessation, sleep, screening for complications, social support

Diabetes care should focus on improving both longevity and quality of life, not glycaemia alone.

MA: How do you address medication adherence challenges in patients with T2DM, and what strategies do you use to improve long-term treatment persistence?

AC: Adherence is influenced by regimen complexity, side effects, cost, health literacy, and patient beliefs. The first step is to understand barriers rather than assume non-adherence.

A key principle is: How can treatment be made easier for the patient? Strategies include simplifying regimens, using fixed-dose combinations, and once-weekly injectables where appropriate. Understanding the patient’s context — work, caregiving, access to food, transport, and finances — is essential, particularly in settings where food insecurity may affect safety and outcomes.

Additional strategies include using agents with low hypoglycaemia risk, shared decision-making, multidisciplinary support, and continuous glucose monitoring to improve engagement.

Ultimately, the best treatment plan is not the most complex, but the one that fits most seamlessly into the patient’s life.

Conclusion

T2DM management is increasingly defined by individualised care, comorbidity-driven decision-making, and early use of therapies that extend beyond glucose lowering to deliver CV, renal, and weight benefits. Optimal outcomes depend on timely treatment intensification, avoidance of therapeutic inertia, and careful selection of agents such as SGLT2i and GLP-1RA. Equally important are lifestyle intervention, patient education, and adherence support. A holistic, patient-centred approach remains essential to improving long-term metabolic control and reducing diabetes-related complications.

Dr Ankia Coetzee is a senior lecturer at Stellenbosch University and a specialist endocrinologist with extensive expertise in internal medicine and metabolic health. Her academic portfolio includes multiple postgraduate qualifications from Stellenbosch University, spanning Internal Medicine, Endocrinology, Diabetes and Metabolism, as well as a PhD in Endocrinology. She also holds a diploma in diabetes management from University of St Andrews. In 2025, she obtained SCOPE certification from the World Obesity Federation, recognising her expertise in obesity prevention and management. Dr Coetzee is known for translating complex endocrine science into practical, patient-centred solutions, with a strong focus on restoring metabolic balance. She is actively involved in international publications, speaker engagements, and media platforms.

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