t2dm-comorbidity-medicine-selector

Guides comorbidity-stratified selection of initial and further glucose-lowering medicines for adults with type 2 diabetes using the NICE NG28 (2026) framework, covering six clinical profiles: no relevant comorbidity, heart failure, atherosclerotic cardiovascular disease, early onset, obesity, chronic kidney disease, and frailty.

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Repository: dromlakhani/MD2SKILL
Letzte Quellaktivität: 19. April 2026 um 18:30
Erkannte Sprache von SKILL.md: Englisch
Sterne: 10
Forks: 1

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npx skills add https://github.com/dromlakhani/MD2SKILL --skill t2dm-comorbidity-medicine-selector

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SKILL.md

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t1d-progression-risk-and-monitoring-frequency

For a person with confirmed islet autoantibodies (early-stage type 1 diabetes), state the numerical progression risk to Stage 3 T1D by stage and age, set the age-stratified monitoring frequency (metabolic and HbA1c), apply the ≥10% longitudinal HbA1c rise → OGTT rule, and give the standard risk-modifier and communication framing. Use when a clinician asks how often should I monitor this Stage 1 child, what's the risk of this teenager progressing to insulin, adult with GAD positive what's the 5-year risk, my patient's HbA1c has risen 12% is that important, single autoantibody how often to retest, or how to counsel a family about progression risk. Grounded in Phillip et al. Diabetologia 2024 international staging and monitoring consensus, cross-referenced with Hussain et al 2026 IDF Europe roadmap.

2026-08-26

t1d-islet-autoantibody-screening-confirmation

Order and confirm islet autoantibody screening for early-stage type 1 diabetes — which antibodies to test (GAD65, IAA, IA2, ZnT8), sample types (capillary dried blood spot, venous), the mandatory two-sample two-method confirmation protocol, and how to interpret a positive, negative, or single-antibody result. Use when a clinician asks how to screen for early T1D, which islet autoantibodies to order, how to confirm a positive T1D antibody screen, is one autoantibody enough for T1D diagnosis, GAD antibody positive what next, or is running a general population or family-history T1D screening program. Grounded in Hussain et al 2026 (Diabetes, Obesity and Metabolism, IDF Europe consensus, DOI 10.1111/dom.70569).

2026-08-25

t1d-staging-classifier

Classify a person with a positive islet autoantibody screen into a specific stage of type 1 diabetes (At Risk / Stage 1 / Stage 2a / Stage 2b / Stage 3a / Stage 3b / Stage 4) using the international consensus staging framework based on autoantibody count and glycaemic status. Use when a clinician asks how to stage a positive autoantibody screen, what stage of T1D is this, is this early-stage T1D, does this child need insulin yet, is this presymptomatic T1D, does this qualify for teplizumab, or presents a person with any combination of islet autoantibodies + glucose data. Applies across paediatric and adult populations. Grounded in Hussain et al 2026 (Diabetes, Obesity and Metabolism, IDF Europe consensus, DOI 10.1111/dom.70569).

2026-08-25

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name	t2dm-comorbidity-medicine-selector
description	Guides comorbidity-stratified selection of initial and further glucose-lowering medicines for adults with type 2 diabetes using the NICE NG28 (2026) framework, covering six clinical profiles: no relevant comorbidity, heart failure, atherosclerotic cardiovascular disease, early onset, obesity, chronic kidney disease, and frailty.
source_guideline	Type 2 Diabetes in Adults: Management (NG28)
publishing_body	National Institute for Health and Care Excellence (NICE)
year	2026
url	https://www.nice.org.uk/guidance/ng28
specialty	Endocrinology / General Practice / Cardiology / Nephrology
version	1.0

Type 2 Diabetes — Comorbidity-Stratified Medicine Selection

Based on: Type 2 Diabetes in Adults: Management (NG28) — NICE (last updated February 2026) Reference: https://www.nice.org.uk/guidance/ng28

PURPOSE

Use this skill when initiating or intensifying glucose-lowering treatment in an adult with type 2 diabetes. The NICE NG28 framework stratifies medicine choice by the person's comorbidity profile rather than a single universal algorithm. This skill identifies the correct comorbidity category, maps it to the guideline-recommended initial regimen, and specifies when and how to add further medicines if glycaemic targets are not met.

STEP 1 — GATHER INFORMATION

Collect the following before selecting a medicine regimen:

Glycaemic status

Current HbA1c (mmol/mol and %)
Individualised HbA1c target already agreed (or needs agreeing — see NICE NG28 Section 1.5)
Current glucose-lowering medicines (drug, dose, duration, tolerability)
Duration since diagnosis

Comorbidity screen — ask and document each:

Heart failure? (any ejection fraction)
Established atherosclerotic cardiovascular disease (ASCVD)? (coronary artery disease, stroke, peripheral arterial disease)
Early onset type 2 diabetes? (defined by NICE as diagnosis before age 40)
Obesity? (BMI ≥30 kg/m², or ≥27.5 kg/m² in South Asian / Black African or Caribbean groups)
Chronic kidney disease (CKD)? If yes: current eGFR (ml/min/1.73 m²)
Frailty? (if suspected, confirm with validated frailty assessment before prescribing)

Safety parameters

eGFR — essential for metformin and SGLT-2 inhibitor dosing and contraindications
Risk factors for diabetic ketoacidosis (DKA): previous DKA, intercurrent illness, very low carbohydrate / ketogenic diet, dehydration
Hypoglycaemia risk: driving / machinery, fall risk, impaired hypoglycaemia awareness
Current use of DPP-4 inhibitor (incompatible with GLP-1 receptor agonists / tirzepatide)
Pregnancy status or intent (separate guidance applies)

Patient factors

Preference regarding injection vs oral route
Adherence concerns or previous intolerances
Weight trajectory and weight target

STEP 2 — RULE IN / RULE OUT

Confirm this skill applies:

Adult with confirmed type 2 diabetes (if treatment response is atypical, revisit diagnosis per NICE NG17 on type 1 diabetes)

Profile	Defining Feature
No relevant comorbidity	T2DM without heart failure, ASCVD, early onset, obesity, CKD, or frailty
Heart failure	Any ejection fraction
Atherosclerotic cardiovascular disease (ASCVD)	Established coronary artery disease, prior stroke/TIA, or peripheral arterial disease
Early onset T2DM	Diagnosis before age 40
Obesity	BMI ≥30 kg/m² (≥27.5 kg/m² in some ethnic groups)
Chronic kidney disease	CKD regardless of cause — eGFR subgroup is critical (see Step 4)
Frailty	Confirmed by validated frailty assessment

Profile	First-Line Offer	If Metformin Contraindicated / Not Tolerated
No relevant comorbidity	Modified-release metformin + SGLT-2 inhibitor	SGLT-2 inhibitor monotherapy
Heart failure	Modified-release metformin + SGLT-2 inhibitor	SGLT-2 inhibitor monotherapy
ASCVD	Modified-release metformin + SGLT-2 inhibitor + subcutaneous semaglutide (Ozempic) up to 1 mg/week	SGLT-2 inhibitor + subcutaneous semaglutide up to 1 mg/week
Early onset T2DM	Modified-release metformin + SGLT-2 inhibitor; consider adding GLP-1 receptor agonist OR tirzepatide	SGLT-2 inhibitor; consider adding GLP-1 receptor agonist or tirzepatide
Obesity	Modified-release metformin + SGLT-2 inhibitor	SGLT-2 inhibitor monotherapy
CKD — eGFR >30	Modified-release metformin + SGLT-2 inhibitor	SGLT-2 inhibitor monotherapy
CKD — eGFR 20–30	Dapagliflozin or empagliflozin + DPP-4 inhibitor	DPP-4 inhibitor monotherapy
CKD — eGFR <20	DPP-4 inhibitor (consider)	Pioglitazone or insulin-based treatment
Frailty	Modified-release metformin; SGLT-2 inhibitor only if frailty does not place person at risk of volume depletion or hypotension	If frailty permits: SGLT-2 inhibitor. If not: DPP-4 inhibitor

Profile	Next Step	If That Is Contraindicated / Not Tolerated / Not Effective
No relevant comorbidity	Add DPP-4 inhibitor	Sulfonylurea OR pioglitazone OR insulin
Heart failure	Add DPP-4 inhibitor	Sulfonylurea OR insulin (note: pioglitazone is contraindicated in heart failure)
ASCVD (new diagnosis after initial Rx)	Add subcutaneous semaglutide up to 1 mg/week	Then: sulfonylurea OR pioglitazone OR insulin
ASCVD (already on semaglutide, needs more)	Add sulfonylurea OR pioglitazone OR insulin	—
Early onset (not on GLP-1/tirzepatide)	Consider GLP-1 receptor agonist or tirzepatide; if not suitable: DPP-4 inhibitor	Sulfonylurea OR pioglitazone OR insulin
Early onset (already on GLP-1/tirzepatide)	Sulfonylurea OR pioglitazone OR insulin	—
Obesity (not on GLP-1/tirzepatide, ≥3 months initial Rx)	Consider GLP-1 receptor agonist or tirzepatide; if not suitable: DPP-4 inhibitor	Sulfonylurea OR pioglitazone OR insulin
Obesity (already on GLP-1/tirzepatide)	Sulfonylurea OR pioglitazone OR insulin	—
CKD	Consider DPP-4 inhibitor; if already on one: pioglitazone OR sulfonylurea (only if eGFR >30) OR insulin	—
Frailty	Consider DPP-4 inhibitor; if not suitable: pioglitazone OR sulfonylurea OR insulin	Warn: sulfonylurea and insulin increase hypoglycaemia and fall risk

t2dm-comorbidity-medicine-selector

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Quelldateien prüfen

Type 2 Diabetes — Comorbidity-Stratified Medicine Selection

PURPOSE

STEP 1 — GATHER INFORMATION

STEP 2 — RULE IN / RULE OUT

Type 2 Diabetes — Comorbidity-Stratified Medicine Selection

PURPOSE

STEP 1 — GATHER INFORMATION

STEP 2 — RULE IN / RULE OUT

STEP 3 — CLASSIFY OR STRATIFY

STEP 4 — DECIDE

INITIAL MEDICINE REGIMEN (first prescription)

FURTHER MEDICINES (HbA1c not at target on initial regimen)

INSULIN-BASED TREATMENT (when indicated across any profile)

STEP 5 — CLINICAL GUARDRAILS

SOURCE

t2dm-comorbidity-medicine-selector

Quellinformationen

Installationsoptionen

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Mehr aus diesem Repository

Mehr aus diesem Repository

Type 2 Diabetes — Comorbidity-Stratified Medicine Selection

PURPOSE

STEP 1 — GATHER INFORMATION

STEP 2 — RULE IN / RULE OUT

Type 2 Diabetes — Comorbidity-Stratified Medicine Selection

PURPOSE

STEP 1 — GATHER INFORMATION

STEP 2 — RULE IN / RULE OUT

STEP 3 — CLASSIFY OR STRATIFY

STEP 4 — DECIDE

INITIAL MEDICINE REGIMEN (first prescription)

FURTHER MEDICINES (HbA1c not at target on initial regimen)

INSULIN-BASED TREATMENT (when indicated across any profile)

STEP 5 — CLINICAL GUARDRAILS

SOURCE