Use the algorithm below to consider the need for insulin in patients presenting with symptomatic hyperglycaemia with blood glucose ≥ 11.1mmol/l .Is the patient ill (vomiting, semi-conscious or clinically dehydrated)?YesNoArrange direct admission to hospital. Does the urine test show moderate/heavy ketonuria?YesNoVery likely to need insulin and high risk of hyperglycaemic emergency. Discuss with specialist team for same day review (or hospital admission). Are one or more of the following present? Severe osmotic symptoms (nocturia x 3-4) Short history (weeks) Marked weight loss (irrespective of absolute weight) A first degree relative with Type 1 Diabetes A personal history of autoimmune disease YesNo Discuss with specialist team. Two or more are a strong indication for insulin. If only single positive AND insulin not indicated consider starting oral medication especially if symptomatic or FPG > 15mmol/l or HbA1c > 69mmol/mol (8.5%). If starting oral medication consider METFORMIN alternatively if BMI < 25 or a rapid therapeutic response is required, prescribe GLICLAZIDE or a combination of the two. Repeat HbA1c in 3 months. When to test for Type 1 Diabetes There is no immediate need for insulin. Give dietary advice on healthy eating and lifestyle changes. + Start oral medication especially if symptomatic or FPG > 15mmol/l or HbA1c > 69mmol/mol (8.5%). If starting medication first line treatment should be METFORMIN alternatively if BMI < 25 or a rapid therapeutic response is required, prescribe GLICLAZIDE Repeat HbA1c in 3 months. When to test for Type 1 Diabetes Is the patient under 30 years of age?YesNo If the patient has a first degree relative on diet or tablets consider the possibility of Maturity Onset Diabetes of the Young (MODY). There is no immediate need for insulin but refer to the specialist team to confirm the diagnosis.