OBJECTIVES: Multiple drug combination therapy aimed at controlling glucose, blood pressure, lipids and fibrinolysis significantly reduces micro- and macrovascular morbidity and mortality in patients with type 2 diabetes. The aims of this study were to (1) identify gaps between current medication management and evidence-based treatment targets in a rural cohort of Australian adults with type 2 diabetes and (2) determine patient factors associated with the prescribing of medications to patients with type 2 diabetes. METHODS: Two hundred and seventy-two medical records were randomly selected from a regional health service type 2 diabetes database. Demographic, biochemical, anthropometric, pharmacological, co-morbidity and lifestyle data during the initial 5 years post diagnosis were collected and analysed. KEY FINDINGS: Five years post type 2 diabetes diagnosis only 12% of the cohort were meeting optimal targets for glucose, blood pressure, low-density lipoprotein, high-density lipoprotein and triglyceride. Younger age (odds ratio, OR 0.96; 95% confidence interval, CI 0.94-0.99; P < 0.05) and elevated urinary microalbumin (OR 1.02; 95% CI 1.01-1.03; P < 0.05) were significantly associated with anti-diabetic medication treatment. The only independent factor associated with pharmacological treatment for hypertension was elevated HbA1c (OR 1.4; 95% CI 1.0-2.0; P < 0.05). Patient factors associated with prescription of lipid-lowering agents were a past history of cardiovascular disease (OR 5.0; 95% CI 2.0-12.5; P < 0.001), concurrent use of anti-hypertensive agents (OR 2.6; 95% CI 1.2-5.8; P < 0.05) and elevated triglyceride (OR 1.9; 95% CI 1.2-3.1; P < 0.01). CONCLUSION: Treatment targets were not being translated into clinical practice in this cohort of patients with type 2 diabetes. Patients with acceptable HbA1c levels, with no history of cardiovascular disease and those taking few medications were at risk of being overlooked for the pharmacotherapy they required.