The large majority of people with type 2 diabetes are cared for in a general internal medicine practice. Only a smaller share needs additional care from an endocrinologist. This article explains why the majority are better served by good internal medicine follow-up. And which signals point towards a switch to a specialist.

In Switzerland, type 2 diabetes is managed primarily by internal medicine, according to the 2023 SGED guideline (Swiss Society of Endocrinology and Diabetology). That means quarterly follow-up checks (HbA1c, blood pressure, kidney values), an annual screening for complications and, in line with SGED 2023, initial treatment as a combination of metformin plus an SGLT-2 inhibitor or a GLP-1 receptor agonist from the outset, since almost everyone affected carries a high cardiovascular risk. Endocrinology takes over for complex insulin regimens, for strong HbA1c fluctuations despite maximal oral therapy, or for diabetes subtypes such as LADA and MODY. For the large majority, the continuity lies with your team. The knowledge of your lifestyle, your comorbidities and your medication. Clinically, that is worth more than frequent specialist visits.

The role of the internal medicine practice: what actually happens.

In Switzerland, most people with type 2 diabetes are looked after in a general internal medicine practice; only a minority are ever referred to endocrinology. Behind this lies a deliberate clinical decision: with a stable HbA1c, a manageable medication regimen and a patient who knows where they stand in daily life, an additional specialist consultation adds hardly any clinical value. What it does cost: time, travel, a second medical history, and often the feeling that something is now "serious".

The internal medicine diabetes consultation consists of three elements. First: the regular follow-up check at least twice a year, in which HbA1c, blood pressure, weight and kidney values are read together. Second: the annual screening. Eyes, feet, kidneys, cardiovascular risk. Third: medication adjustment, which moves in defined steps and in which the comorbidities count for more than the glucose figure alone.

Medication: metformin, SGLT-2, GLP-1. Who does what.

The medication cascade for type 2 diabetes has become broader over the past ten years, and at the same time clearer. SGED 2023 recommends initial treatment as a combination of metformin plus an SGLT-2 inhibitor or a GLP-1 receptor agonist from the outset, since almost everyone affected carries a high cardiovascular risk. SGLT-2 inhibitors (dapagliflozin, empagliflozin) lower blood glucose and additionally protect the heart and kidneys, with particular benefit in heart failure and chronic kidney disease. GLP-1 agonists (semaglutide, liraglutide) are the preferred choice when weight reduction is clinically relevant or when the target values are not reached with the first combination.

All of this can be managed by internal medicine. What endocrinology offers becomes interesting when insulin comes into play. Basal insulin, prandial insulin, mixed regimens, when HbA1c cannot be kept below 7.5 percent despite triple oral therapy, or when the clinical picture suggests a different type of diabetes (LADA in adulthood, MODY with familial clustering early in life).

When a switch to endocrinology makes sense.

According to the SGED, the following situations count as a clear indication for shared care with an endocrinologist. Endocrinology complements Dein Team here rather than replacing it. In our practice we call this "shared management": Dein Team remains your first point of contact, and endocrinology takes on the complex part of the therapy.

  • Insulin dependence and a complex basal-bolus therapy.
  • An HbA1c above 8.5 percent despite three oral agents.
  • Suspected LADA (latent autoimmune diabetes in adults).
  • Suspected MODY (familial clustering, onset before the age of 25).
  • Planned or existing pregnancy.
  • Recurrent hypoglycaemia on insulin or sulfonylureas.
  • Very unstable blood glucose without an explainable cause.

What the diabetes consultation at Dein Team looks like.

At Dein Team fürs Leben, every patient with type 2 diabetes gets a quarterly follow-up window that is booked ahead in the calendar. We measure HbA1c, blood pressure and kidney values. We go through your medication list. We ask you what daily life with the condition looks like. Sleep, work, exercise, appetite. Once a year we extend this into an annual review: ophthalmologist, foot check, extended cardiovascular profile. If one of the triggers listed above appears, we organise shared care with endocrinology. And we remain Dein Team.

:::cta-box{variant=alpine headline="Diabetes also has a cardiological side" body="Type 2 diabetes measurably raises cardiovascular risk. Which therapy lowers it today, and from what point a cardiological assessment makes sense, you can read on the sister hub dth.healthcare." url="https://dth.healthcare/diabetes-herzrisiko" label="To the DTH companion: diabetes and the heart"}